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NATIONAL LIBRARY OF MEDICINE 

Bethesda, Maryland 



TREATISE ON THE DISEASES 



AND 



PHYSICAL EDUCATION 



OP 



CHILDREN, 



BY JOHN EBERLE, M. D 



PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE MEDICAL COLLEGE 

OF OHIO; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY; OF THE 

ACADEMY OF SCIENCES OF PHILADELPHIA; CORRESPONDING! 

MEMBER OF THE MEDICO-CHIRURG1CAL SOCIETY 

OF BERLIN, IN PRUSSIA, &C. &C. 




CINCINNATI: 
PUBLISHED BYCOREYAND FAIRBANK; 



PHILADELPHIA: GRIGG AND ELLIOTT. 



f 



1833. 



Entered according to act of Congress, in the year 1833, by 

JOHN EBERLE, M. D., 

in the Clerk's Office of the District of Ohio. 



PRINTED BY J. A. JAMES.. ..CINCINNATI, OHIO. 



€ 






• 



TO 

N . R . SMITH, M . D . , 

PROFESSOR OF SURGERY IN THE UNIVERSITY OF MARYLAND, &c. &c. 

THIS WORK IS RESPECTFULLY 

INSCRIBED, 

AS AN HUMBLE ACKNOWLEDGMENT OF THE HIGH REGARD ENTERTAINED 

FOR HIS PROFESSIONAL TALENTS, AND PRIVATE WORTH, 

BY HIS FRIEND AND FORMER COLLEAGUE, 

THE AUTHOR. 



CONTENTS. 



BOOK I. 

OF THE PROPHYLACTIC, AND PHYSICAL MANAGE- 
MENT OF CHILDREN. 

CHAP. I. Of the conduct of mothers during pages. 

Pregnancy, - 1 
II. Of the Management of new-born 

Infants, - - - 17 

III. Of the Nourishment of Infants, 25 

IV. Of Exercise, - - - 43 
V. Air — Temperature — Exposure, 51 

VI. The Nursery, - - - 58 

VII. Of Weaning, - - 61 

VIII. Cleanliness. Washing. Bathing, 72 



BOOK II. 

OF THE DISEASES OF CHILDREN. 

CHAP. I. Of Syncope, Asphyxia, and Imper- 
fect Respiration, - 77 
II. Of the Meconium, - - 88 

III. On the Tongue-Tie, - 92 

IV. Of the Inflammation and Swelling 

of the Breasts of new-born Infants, 94 



CONTENTS. PAGES. 

V. Of Inflammation and Ulceration of 

the Navel, - - - 96 

VI. Of the Jaundice of Infants, 99 
VII. Of the Retention and Suppression 

of Urine, - - - 109 
VIII. Of Dysuria— or Painful and Diffi- 
cult Micturition, - - 115 
IX. Of Enuresis — or Incontinence of 

Urine, - - 120 

X. Of Dentition, - - 125 

XI. Of the Diabetes of Infants, - 145 

XII. Of the Erysipelas of Infants, 150 

XIII. Induration of the Cellular Membrane 

and Skin. Skinbound, - 162 

XIV. Of the Coryza of Infants, - 168 
XV. Of the Aphtha of Infants. Thrush, 171 

XVI. Ulceration of the Mouth, - 183 

XVII. Of Colic, - - 187 

XVIII. Of Constipation, - 201 

XIX. Of Vomiting, - - 205 

XX. Of Diarrhoea, - - 211 

XXI. Of Intestinal Worms, - 255 

XXII. Of Ophthalmia— - - - 269 

XXIII. Of Cholera Infantum, - - 283 

XXIV. Of the Remittent Fevers of Infants, 300 
XXV. Catarrh. Catarrhal Fever, - 318 

XXVI. Acute Bronchitis, - - 327 

XXVII. Pleuritis, - - - 332 

XXVIII. Parotitis. Mumps, - - 336 
XXIX. Tonsillitis. Cynanche Tonsillaris. — 

Quinsy, - - - 339 
XXX. Cynanche Trachealis. Tracheitis. 

Croup, - - -I 344 



( 





CONTENTS. ] 


PAGES. 


XXXI. 


Cynanche Laryngea, 


365 


XXXII. 


Arichnitis. Hydrocephalus. Dropsy 






in the Brain, 


370 


XXXIII. 


Peritonitis. Ascites, 


391 


XXXIV. 


Vaccina. Vaccine Disease, 


396 


XXXV. 


Modified Small Pox, - 


411 


u 


Sect. 1. Varioloid Disease, 


411 


a 


" 2. Varicella, 


417 


XXXVI. 


Rubeola, Morbilli. Measles, 


428 


XXXVII. 


Scarlatina. Scarlet Fever, 


443 


XXXVIII. 


Pertussis. Whooping Cough, 


469 


XXXIX. 


Convulsive Affections of Infants, 


489 


XL. 


Infantile Epilepsy, 


508 


XLI. 


Carpo-Pedal Spasms, 


525 


XLII. 


Chronic Eruptive Affections, 


533 


XLm. 


Inflammation and Abscess within 






the Ear, - 


545 



BOOK I. 

OF THE PROPHYLACTIC AND PHYSICAL MANAGEMENT 
OF CHILDREN. 



CHAPTER I. 

OF THE CONDUCT OF MOTHERS DURING PREGNANCY. 

That the foetus may be variously and injuriously affected, by 
causes acting through the medium of the maternal system; and 
that disease and constitutional infirmity are thus often produced 
during the uterine stage of life does not appear to admit of a 
doubt. From the moment, therefore, that conception has taken 
place, a new and most sacred duty devolves upon the female. She 
is bound by all the ties of maternal sentiment, of humanity and 
of moral and religious obligations to protect the nascent being in 
her womb, against every circumstance under her control, which 
may have an unfavourable influence on its delicate and uninured 
organization. 

Though not in itself a state of disease, pregnancy is evidently 
attended, in the majority of instances, with a decidedly increased 
aptitude to morbific influences. Augmented sensibility and irri- 
tability of the nervous and sanguiferous systems, appears to be a 
natural concomitant of all great efforts of physical development 
in the animal organization. We observe it in dentition, and at 
the age of puberty, and it is, in general, equally strongly marked 
during the progress of those important developments which take 
place in the female system, from the commencement to the com- 
pletion of gestation. When to this we add the remarkable 
tendency to general plethora, and the rise of the various powerful 
and pervading sympathies which occur during pregnancy, we 
have a combination of circumstances peculiarly calculated to in- 
crease the liability to disease and injury, from the influence of 
exciting and irritating causes. 
B 



2 OF THE CONDUCT OF MOTHERS 

Without doubt, many instances of pregnancy occur in which 
good health is enjoyed throughout its whole course, although 
little or no particular care is taken to avoid the usual sources of 
injury in such cases. Very frequently, however, the reverse ob- 
tains; and we daily witness much suffering and danger, both to 
the mother and child, from the influence of causes which, with 
proper care, might be avoided or rendered inoffensive. 

The most serious, and perhaps, most common injurious conse- 
quence resulting from errors in this respect is abortion. Females 
are not, in general, sufficiently impressed with the great im- 
portance of attending to the precautionary measures, which reason 
and experience dictate, in relation to the prevention of this acci- 
dent. They are apt to look upon abortion, as a temporary evil — 
an affair of a few hours, or at most of a few days suffering, and 
generally of no other serious consideration than that which may 
be due to the premature destruction of the embryo. This con- 
sideration might, indeed, be deemed a sufficient motive for the 
exercise of adequate care in this respect; but it may well be 
doubted, whether it often receives the regard which a proper sense 
of duty would dictate. In addition, however, to this appeal to 
the moral sentiment of the mother, there are other circumstances 
in relation to her own welfare, which when properly presented to 
her mind, seldom fail to excite a suitable attention to this import- 
ant subject. Besides the very distressing circumstance that 
abortion, is in general peculiarly liable to recur, after having once 
taken place, we may mention the following as among the ordinary 
evil consequences of this accident — namely leucorrhoea, menorr- 
hagia, dysmenorrhea, prolapsus uteri; schirrus uteri, various 
nervous affections, especially chronic hysteria, dyspepsia, and 
general debility and ill-health. It is indeed a very rare occurrence 
to meet with a healthy female who has aborted more than once. 
Permanent injury to health is much more apt to result from 
abortion than from regular parturition. The benevolent author of 
nature has endowed every being with powers adequate under 
ordinary circumstances, to sustain the natural operations which it 
is destined to perform, without any particular evil consequences. 
The premature separation and expulsion of the foetus, however, 
is an occurrence contrary to the design and regular course of 
nature and can not take place without more or less violence to 
the system and consequent disorder and infirmity. 

But it is not simply with the view of obviating this accident, 
that the pregnant female is so deeply concerned in guarding 
against the operation of injurious causes. The future health and 
vigour of the child may be materially affected by the conduct 
of the mother in this respect. Organic debility and morbid 
predispositions may be thus produced, which, in their ultimate 



DURING PREGNANCY, 3 

consequences, may prove more afflicting than abortion itself. It 
has indeed been supposed, that as there exists no direct or con- 
tinuous communication between the foetus and the mother, either 
by the blood vessels or the nerves, the former, probably, never 
participates to any serious extent, in the general diseases of the 
latter. It is observed that infants, well nourished, and apparently 
in good health, are occasionally born of mothers who had laboured 
under severe and irremediable disease during the whole period of 
gestasion. This is doubtless the case in many instances ; but it should 
be observed that although the new-born infant may appear to 
enjoy a good state of health, it frequently happens that the disease 
or predisposition contracted during gestation, remains latent or 
dormant for months or even years after birth, before it is de- 
veloped; and thus, there may be the appearance of a sound and 
healthful state of the constitution, during infancy, although the 
seeds of disease may be deeply deposited in the system. The 
want of a continuous vascular or nervous communication between 
the fcetus and the mother, can not be regarded as a sufficient 
ground for denying the possibility of the passage of disease 
from the maternal to the fcetal system. The fact that syphilis 
and small-pox, not to mention various other affections, have been 
contracted by the fcetus in utero, furnishes conclusive evidence 
of the occasional transmission of disease from the mother to the 
fcetus. In the higher grades of miasmal fever, particularly in 
yellow fever, miscarriage is by no means uncommon; and in many 
instances of this kind, the child is born dead, and often with 
evident marks of having died several days previous to its expulsion 
from the womb. It is nevertheless probable that the influence 
of maternal disease, or of injurious causes acting through the 
mother's system on the fcetus, when not sufficiently powerful to 
excite abortion, is generally confined to the production, rather 
of organic feebleness and predisposition to disease, than to any 
active state of morbid excitement or positive malady. Be this as 
it may, the liability of the child to injurious impresssions, during 
its uterine existence, is abundantly verified by observation; and 
experience and reason justify the conclusion, that the welfare of 
the fcetus, in relation both to its physical and moral conditions, is 
intimately connected with the health and regularity of the ma- 
ternal system — and consequently, so far under the control of the 
mother, as she may have it in her power, to avoid the sources 
of disease and inordinate excitement. 

I. Of the dietetic regulations proper during pregnancy. — The 
peculiar tendency to febrile irritation and general plethora, so 
apt to accompany pregnancy, renders it especially proper to 
avoid the sources of undue excitation and nourishment during 
this period. The sensibility of the stomach, too, almost always 



4 OF THE CONDUCT OF MOTHERS 

undergoes peculiar modifications; and the remarkable activity of 
its sympathies, more especially with the uterine system, attending 
most instances of pregnancy, presents us with an additional reason 
for the adoption of proper dietic regulations during the progress 
of gestation. 

It is not to be inferred, indeed, that the pregnant female unless 
labouring under some disease, is to be dieted like a valetudinarian; 
but admitting a substantial and adequate diet, we are nevertheless 
warned by experience, to enjoin that moderation and simplicity 
of food, which would always be best, but which is now especially 
proper; and to caution against the free use of heating or particu- 
larly stimulating ingesta. As the appetite is frequently very 
craving in pregnancy, an inordinate indulgence in rich and high 
seasoned food is among the most common errors of females during 
this period. This error is the more apt to be committed, from the 
erroneous idea which many entertain, that, as the foetus in utero 
draws its nourishment from the maternal system, a greater quantity 
of aliment is required in pregnancy than is necessary in the un- 
impregnated state. Dr. Dewees, in his work on the diseases of 
children, has placed the fallacy and injurious tendency of this 
opinion in a very strong light. The eight or ten pounds of animal 
substance which goes to the composition of the fully developed 
fcetus, being gradually drawn from the mother during a period 
of nine months, can not, surely, require any particular increase in 
the nourishment taken by the mother — more especially, " as almost 
every individual habitually takes more food, than is required for 
the regular support and health of the system." 

The evils which are liable to result to pregnant females from er- 
rors in diet, are various and often exceedingly distressing. Where 
a predisposition to abortion exists, the free use of very nourishing 
and stimulating articles of diet, may give rise to this accident, 
simply by favouring the usually prevailing tendency to general 
plethora and fever. The occurrence of indigestion and gastric 
irritation, also, is particularly calculated to produce serious conse- 
quences in pregnancy. I have known several instances where the 
use of indigestible and irritating articles of food gave rise to the 
most alarming irritation of the stomach and bowels, attended with 
severe vomiting, and followed very speedily by abortion. In one 
case, a young married woman, in the fourth month of her first 
pregnancy, was seized with excruciating and obstinate dyspeptic 
colic, soon after she had eat freely of some very indigestible food. 
Notwithstanding the great risk and suffering which she had under- 
gone from this attack, which she could not but refer to its true 
cause, and while her stomach was still weak and irritable, the 
strong cravings of her appetite led her, in about ten days after, 
to commit a similar, but still more glaring error. The consequence 



DURING PREGNANCY. 5 

was, another violent attack of colic, followed immediately by in- 
flammation of the bowels, which in the course of the second day 
terminated in abortion, and on the following day in the death of 
the patient. 

The exercise of caution, in the selection of proper food for 
pregnant females, appears to be particularly important towards 
the termination of gestation. The occurrence of gastro-intestinal 
irritation and dyspeptic colic, at this period, besides its tendency to 
excite miscarriage, seems to be particularly favourable to the 
supervention of peritonitis, after the delivery of the child. There 
is another circumstance in relation to this subject, which appears 
to be well entitled to attention. There is a chronic form of intes- 
tinal irritation, which results from the impression of vitiated 
secretions, or unnatural and inordinately accumulated foecal 
matter, and which, though not often manifested by any very 
conspicuous morbid effects during gestation, often exerts an 
alarming and fatal influence on the system, within a short period 
after parturition has taken place. A redundant, mixed, hetero- 
genous, and not sufficiently digestible diet, is especially apt to lead 
to this condition of the bowels, where the digestive functions are 
not very vigorous, and the alvine evacuations insufficient. The 
consequences which are liable to result from intestinal irritations 
of this kind, are: great prostration; puerperal convulsions; alarm- 
ing nervous affections; severe head-ache; pain in the lower part 
of the abdomen; inability to sleep; and a peculiar and highly 
dangerous affection, resembling puerperal fever, characterized by 
a remarkable sinking of the vital energies. That the liability to 
this very alarming form of puerperal disease, is greatly enhanced 
by errors in diet, — more especially by excess in the quantity of 
food taken, during the later stage of gestation admits of no doubt. 
I have witnessed several instances in which the correctness of this 
observation seemed to me very strikingly exemplified. A lady 
who had enjoyed unusually good health previous to her pregnan- 
cy, but who could not be restrained from indulging her appetite 
to an improper extent, became affected with severe and painful 
diarrhoea, about the middle of the last month of gestation. By 
the adoption of proper dietetic regulations, and the employment 
of suitable medicines, the disease subsided in the course of seven 
or eight days. A few days, however, before the termination of 
the pregnancy, she indulged to excess in eating plum-pie with a 
full proportion of strong cheese, "to help the stomach to digest" 
the farrago she had swallowed. Diarrhoea was re-excited; and 
in a few days after she was delivered of a healthy child. On the 
second day after parturition, she experienced a slight chill, fol- 
lowed speedily by symptoms simulating puerperal fever, attended 
with irresistible prostration and sinking of the vital energies, which 



6 OF THE CONDUCT OF MOTHERS 

terminated in death on the fourth day. These violent and dan- 
gerous effects of intestinal irritation are, fortunately, not very 
common; but there are many other affections of a discomforting, 
and often distressing character, which are rarely entirely escaped, 
by those who neglect a prudent attention to dietetic observances. 
Flatulency, acid eructations, pains in the stomach and bowels, 
cephalalgia, hysteria, diarrhoea, a feverish and restless state of the 
system, depression of spirits, palpitations, not to mention various 
other disturbing affections, are among the ordinary consequences 
of a habitual disregard of proper regulations, in relation to the 
diet. The pregnant female who observes a suitable regimen, will 
ceteris paribus, always enjoy more tranquility both of mind and 
body, and incur much less risk of injury to herself and child, than 
she, who giving a free rein to her appetite, indulges it to excess, 
or in the use of improper articles of food. 

With regard to the particular dietetic regulations proper during 
pregnancy, it may be observed that moderation and simplicity in 
diet, are in general of more importance to the health and comfort 
of the female, than any very cautious selection as to the kind of 
food. This remark is more especially applicable to females en- 
joying a good state of health or who are free from any particular 
derangement of the digestive functions. A healthy female may, 
without risk of injury from this source, continue to take the same 
kind of nourishment during gestation, to which she was accustom- 
ed, and by which her health was maintained previous to the 
occurrence of pregnancy. Where the digestive powers are very 
active and there exists a decided tendency to plethora and febrile 
excitement, however, it will be proper to avoid the more stimu- 
lating and nutritious articles of food. In such cases, a diet con- 
sisting principally of the more digestible kinds of vegetable 
aliment should be selected, and all heating or strong stimulating 
drinks rigidly avoided. 

In cases attended with a weak and irritable state of the stomach, 
a continued attention to the selection of suitable articles of nourish- 
ment is particularly important. In instances of this kind, the 
most distressing and alarming consequences are apt to result from 
errors committed in this respect. The necessity of enjoining un- 
interrupted attention to the choice of proper articles of food, when 
the digestive organs are in this condition, is the more urgent, from 
the circumstance that in cases of this kind, the appetite is fre- 
quently very craving and capricious, requiring a degree of 
resolution and forbearance which is seldom witnessed, until actual 
suffering gives efficiency to the counsels of prudence and expe- 
rience. In general, such cases require the management proper in 
dyspepsia. Mild, unirritating, digestible and adequately nourish- 
ing food, must be selected. Rice, barley, arrow-root, oat-meal, 






DURING PREGNANCY. 7 

milk, the lean parts of mutton, lamb, venison, tender "beef, soft- 
boiled eggs, stewed apples and peaches, constitute appropriate 
articles of nourishment in such cases. It should be observed, 
moreover, that moderation in eating, as well as simplicity in the 
variety of the articles of food, are indispensible to the comfort and 
health of the patient under these circumstances. It matters not how 
suitable the diet may be as to its character; much, if not all the 
advantage which might result from it, under a temperate use, will 
be prevented, if it be taken in larger portions than the stomach is 
capable of digesting. Coffee and tea, when not made very 
strong, seldom give rise to any obvious inconvenience or disorder, 
and may in general, be used with perfect propriety during the 

feriod of gestation, by females enjoying an ordinary state of health, 
n subjects of a decidedly nervous temperament, however, or in 
such as are labouring under a morbidly irritable state of the ner- 
vous system, the use of strong coffee, and more especially of strong 
green tea, should be interdicted as a habitual beverage at meals. 
In such cases, black tea or well prepared chocolate, may in 
general be taken with entire safety. Milk, more or less diluted 
with water, is also an excellent drink in habits of this kind. 
With regard to vinous or alcoholic drinks, it is scarcely possible 
to reprobate their habitual use, in terms of censure sufficiently 
strong. Excepting as mere medicinal agents, regularly prescribed, 
they ought to be wholly and most rigidly avoided by pregnant fe- 
males. The temptation, as Dr. Dewees very truly observes, to 
taking small portions of cordial or brandy, in the early months of 
gestation, is often very strong. The annoying sensations frequently 
experienced in the stomach, and the general uncomfortable feel- 
ing connected with them, are, usually, allayed or moderated for 
a time, by the use of these potent stimuli. The unpleasant 
feelings, however, return, and recourse is again had to the 
assuaging but insidious stimulus; and thus it is taken again and 
again, in still increasing portions, until the deplorable habit of 
solitary dram-drinking is formed, and the health, happiness, and 
character, of, perhaps, an otherwise amiable and excellent being, 
immolated to the filthy and devastating demon of inebriety. 
The frequent or habitual use of spirituous drinks, is particularly 
apt to favour the occurrence of abortion. In the course of my 
practice I have met with some very striking exemplifications of 
this fact. A lady, who, after the birth of her first child, became 
deeply imbued with this lamentable vice, aborted four times in 
succession. She then, by the earnest and unremitting exertions 
of her friends, seconded by her own efforts, succeeded in throwing 
off the habit of intemperance, and in the course of the following 
ten years gave birth to four children. These children, however, 
were remarkably feeble and sickly from their birth, and one only, 



8 OF THE CONDUCT OF MOTHERS 

out of the four, is now living — about six years of age, and mani- 
festly of a very delicate and infirm constitution. Examples of the 
very ruinous effects of habitual intoxication on the health and life 
of the fetus in utero, are unfortunately, but too common. The 
majority of children born of decidedly intemperate mothers, are 
weak and sickly, and but few of them arrive at the age of adoles- 
cence. Many females appear to think, that although these and 
other melancholy consequences, follow in the train of habitual in- 
temperance, it is extremely improbable that any injury can result 
to themselves or the foetus, from the occasion al use of small 
portions of spirituous liquors. Were it indeed absolutely certain, 
that the use of such potations, would always be restricted to oc- 
casional small portions, the indulgence would perhaps, rarely 
occasion any serious consequences. But as no prudence and 
resolution can be safely regarded as an entire protection against 
the gradual formation of the habit of intemperance, where such 
drinks are occasionally taken during gestation, even though it be at 
very considerable intervals and in very moderate quantities at first, 
it is far the safest plan, to abstain wholly from every kind of 
spirituous liquors. The propriety of total abstinence, is the more 
obvious, from the undeniable fact, that whatever temporary me- 
lioration of the feelings which may, at times, result from the use 
of spirituous drinks, they very frequently contribute, ultimately, 
to increase the infirmity or mischief for which they were taken. 

Before leaving this part of the present subject, it will be proper 
to make a few remarks upon that remarkable irregularity of the 
appetite, or " longing" as it is called, which many females expe- 
rience during pregnancy. The appetitive sensibilities of the 
stomach undergo so much derangement in some instances, that 
articles of food, which previous to the occurrence of pregnancy 
were very grateful and congenial, become highly disagreeable, 
and an almost irresistible craving for unnatural and even disgust- 
ing substances is experienced. In general, this aberration of the 
appetite, is more apt to occur in weak and delicate females of a 
nervous temperament, than in such as are of a robust and full habit 
of body. Different opinions have been expressed with regard to 
the probable influence, which entirer resistance to these vehement 
longings or disppointment in satisfying them, may have on the 
mother and foetus. It is not unreasonable to presume, that the 
strong mental affection which may be caused by disappointment 
in this respect, may exert an unfavourable influence on the health 
of the mother and child, more especially in very nervous and ex- 
citable females. Disappointment, and its consequent moral 
affection, from this source, however, has nothing peculiar in its 
influence, and can be no more injurious in its reaction on the 



DURING PREGNANCY. 9 

system than an equally strong emotion of the mind, from any 
other source of disappointment or frustrated desire. 

If the substances longed for he not evidently of an injurious 
character, they should not be withheld. The mind is always more 
or less tranquilized by gratification, and, unless the indulgence be 
carried to an immoderate extent, it will very rarely occasion any 
particular disturbance. It is very remarkable, indeed, that even 
unwholesome articles, seldom give rise to any particular inconve- 
nience or disturbance in the system, where there is a very urgent 
and persisting desire experienced for them. Still it would not be 
prudent to trust too much to this power of the stomach to resist 
the injurious impressions of the substances it calls for; and whenever 
the appetite is thus directed upon articles of an offensive or hurt- 
ful nature, means should be used to divert if and determine it to 
more suitable alimentary substances. In some instances, these 
"longings" must be regarded as instinctive calls of the stomach, 
favourable to the health of the individual. If they are not grati- 
fied, langour, inquietude and other symptoms of deranged health, 
will be very apt to supervene. Thus when a strong desire for 
eating chalk, charcoal, clay, &c.is manifested, we are admonished 
that the digestive powers are feeble, and that there exists a pre- 
vailing tendency to acidity in the stomach. In such cases, the 
appropriate means of relief are alkalines,mild laxatives, and tonic 
vegetable bitters, with a suitable regimen. Magnesia in combi- 
nation with some vegetable bitter, or the bi-carbonate of potash 
with small portions of aloes, or rhubarb, so as to procure one or 
two free alvine evacuations daily, seldom fail to procure some ad- 
vantage. If the tongue is bitter and clammy, small doses of blue- 
pill, with an occasional mild purgative, and moderate portions of 
sulphuric or nitric acid, three or four times during the day, will 
tend to bring the stomach back from its aberrations, to a more 
healthy tone of feeling. It is not common, however, to find these 
irregular determinations of the appetite so strong or so decidedly 
injurious in their tendency, as to require any particular medical 
attention; and we rarely meet with instances which may not be 
moderately indulged, without injury or inconvenience to the 
system. 

II. Of the proper regulations in relation to dress and exercise. — This 
is a most important subject of attention to females during the 
period of gestation. Some of the prevailing customs in relation 
to dress, are so obviouslv improper during pregnancy, that it 
would seem very strange that there should be any difficulty in 
procuring their temporary rejection by females in this condition, 
did we not know that the imperious commands of fashion are often 
more sedulously obeyed, than the dictates of humanity and of self 
preservation. The custom of wearing tightly laced corsets during 



10 OF THE CONDUCT OF MOTHERS 

gestation, can not be too severely censured. It must be evident 
to the plainest understanding, that serious injury to the health, 
both of the mother and child, must often result from a continual 
and forcible compression of the abdomen, whilst nature is at 
work in gradually enlarging it, for the accommodation and devel- 
opment of the foetus. By this unnatural practice the circulation 
of the blood throughout the abdomen is impeded — a circumstance, 
which together with the mechanical compression of the abdominal 
organs, is peculiarly calculated to give rise to functional disorder 
of the stomach and liver, as well as to hsemorrhoids, uterine haemor- 
rhage and abortion. The regular nourishment of the fcetus, also, 
is generally impeded in this way, — a fact which is frequently 
verified in the remarkably delicate and emaciated condition of 
infants, born of mothers who have practised this fashionable folly 
during gestation. It may be observed, that since the custom of 
wearing tightly laced corsets has become general among females, 
certain forms of uterine disease are much more frequent than they 
were, previous to the re-introduction of this fashion. My expe- 
rience has satisfied me, that leucorrhcea and prolapsus uteri, are 
vastly more common at the present day, among unmarried females, 
than they were sixteen or eighteen years ago. It is indeed aston- 
ishing, that these disorders are not more frequent even than they 
appear to be; for we can not conceive of any cause more directly 
calculated to produce them, than the prevailingpractice of pressing 
the abdominal viscera down upon the womb, and thus forcing it 
out of its natural position, into the lower part of the pelvis, where 
the irritation it causes, gives rise to leucorrha?al discharge. Struve 
observes, in relation to the injurious tendency of wearing corsets 
during gestation, " that the parts which have suffered from con- 
stant pressure, become debilitated and incapable of co-operating 
in the important function of parturition; so that the passage of the 
child is endangered, the labour rendered more tedious and pain- 
ful, and all the operations of nature retarded." The pressure 
of corsets, moreover, must tend to debilitate both the mother and 
infant, by impeding the function of respiration, and preventing in 
some degree, the regular decarbenization of the blood. Struve 
cautions pregnant females against an error, which is not likely to 
be committed in the present mode of dressing — namely, " to avoid 
wearing a number of heavy petticoats, by which the abdomen may 
be depressed, and a bad position of the foetus produced. At the 
present day, it is much more necessary to caution against the 
opposite impropriety, of using insufficient clothing to protect the 
body from the injurious influence of cold and atmospheric vicissi- 
tudes. The abdomen and feet especially, should be guarded 
against injury from these causes. In the winter or cold and damp 
reasons, the use of a broad flannel or bandage or roller round the 



DURING PREGNANCY. 11 

abdomen, is very useful in this respect, and may be beneficial 
moreover, by the uniform support which it affords to the abdomen 
and its consequent tendency to obviate any unfavourable obliqui- 
ties in the position of the womb, in the advanced periods of 
gestation. 

The exercise which it may be proper to use during pregnane}', 
must of course, vary according to the period of gestation, and the 
particular condition of the female in relation to constitutional 
vigour, predisposition to abortion, and other affections, previous 
habit, and temperament. All kinds of "agitating exercise, such 
as riding in carriages with rapidity over rough roads, dancing, 
lifting, or carrying heavy loads, in short, all masculine and fatiguing 
employments whatever," ought to be avoided by pregnant women. 
The propriety of avoiding agitating and fatiguing exercise, in- 
creases in proportion as gestation approaches the term of its 
regular completion. During the eighth or ninth month of preg- 
nancy, unusual corporeal exertion or fatigue, is particularly apt to 
excite premature labour; and where this accident has once taken 
place the necessity of observing proper caution in this respect, in 
subsequent pregnancies, is peculiarly urgent. In all instances, 
where a predisposition exists to abortion at any particular period, 
it is scarcely possible to prevent its occurrence, unless the utmost 
degree of care is taken, to avoid exciting or fatiguing exercise, 
about the time when this accident is apt to take place. 

In weak, excitable, and nervous females, and in such as are of 
an unusually plethoric and irritable habit of body, it is particularly 
proper to observe suitable precautions, in relation to exercise and 
corporeal exertion. It is to be observed, however, that if injury is 
apt to result from too much exercise and agitation of the body, there 
is reason also for apprehending injurious consequences from too 
much indolence and inactivity. Moderate and gentle exercise is 
generally decidedly salutary during gestation, and should not be 
neglected unless some particular reason exists for maintaining a 
6tate of rest and bodily composure. Riding, in an easy carriage, on 
even roads, or moderate walking, may be enjoyed with great pro- 
priety, and usually with obvious advantage during gestation. 

III. Of moral influences. — Tranquility and cheerfulness of mind 
are always highly favourable to the health and regular operations 
of the animal economy. In pregnancy, the importance of a calm 
and even temper is especially great; for the re-action of mental 
agitation or depression, is capable of producing very unfortunate 
impressions, both upon the mother and foetus. Violent anger, 
terror, or jealousy seldom fail to produce unpleasant effects during 
pregnancy; and the consequences are, sometimes, very alarming, 
and even fatal. Convulsions, severe paroxysms of hysteria, spasms, 
syncope, insensibility, haemorrhage, and abortion, may be pro- 



12 OF THE CONDUCT OF MOTHERS 

duced by moral influences of this kind. Not more than ten months 
ago, I witnessed the occurrence of hysteric convulsions followed, 
in the course of a few hours by abortion, in consequence of a fit 
of vehement rage from jealousy. But even when none of these 
violent affections result from the more agitating emotions, there 
are various minor evils of a discomforting and distressing charac- 
ter, which are apt to occur during pregnancy from moral influences 
of this nature. The functions of the stomach, the heart, the liver, 
and of the brain itself, are strongly influenced by the mind. The 
depressing moral affections often exert a highly injurious influence 
on the organization, particularly on the digestive and biliary 
organs. Debility, indigestion, jaundice, emaciation, with various 
other functional disorders, and even organic affections, are fre- 
quently produced by emotions of this kind; more especially by 
intense and protracted grief, and mental distress. Unfortunately 
no effort of the will, or firmness, is always adequate to avoid these 
distressing affections of the mind. The accidents and misfortunes 
to which all are liable, sometimes bring grief, and sorrow, and 
distress, with a force which cannot be sufficiently resisted. There 
are, however, other causes of mental disturbance, which are more 
under the control of well constituted minds; and which are almost 
as detrimental to the v. elfare of both the mother and child, as the 
moral affections just referred to. Fretfulness and moroseness of 
temper; envious and jealous feelings, peevishness, hatred, discon- 
tent, obstinacy and perverseness of disposition, are under the 
subjection of reason and a sense of propriety. It is of great im- 
portance to the regular progress of gestation and to the well-being 
of the mother and foetus, that every effort which good sense and 
moral feeling dictate, should hr steadfastly made by pregnant fe- 
males, to keep down these injurious and degrading sentiments and 
irregularities of temper. 

The maternal imagination has been accused of producing the 
most extraordinary effects on the foetus in utero. During the early 
and middle ages, it was almost universally believed, that malfor- 
mations, moles, and other unnatural appearances, were xery 
generally produced by the influence of the imagination of mothers; 
and the opinion continued to prevail with many reflecting and 
well informed physicians, until within a comparatively late period. 

A multitude of pretended examples of this kind, are on record 

many of which are of a character so strikingly preposterous and 
impossible, that they can now be regarded only as extraordinary 
and humiliating instances of human credulity. We are told, that 
black children have been born of Avhite parents, in consequence 
of the maternal imagination having been excited by contempla- 
ting the portrait of an Ethiopan, and the same effect has been 
produced, according to some statements, in consequence of preg- 



DURING PREGNANCY. 13 

nant females having contemplated with interest the portrait of an 
Ethiopian, or having 'been frightened by a black man. Damas- 
cenes assures us, that he saw an infant born with the whole of its 
body covered thickly with coarse black hair, caused, as he states, 
by the mother having frequently looked at an image of St. John 
dressed in a bear's skin. A child was born at Blois in France, 
with the iris of one of its eyes accurately representing the dial- 
plate of a watch, in consequence of the mother having experi- 
enced a very strong desire to have a watch, which from some 
cause or other could not be gratified. 

Absurdities of this gross and glaring character are now but little 
entertained even by the most superstitious and ignorant. There 
are still, however, some, who fancy that under strong excitement 
the imagination is capable of producing indelible impressions on 
the body of the foetus in utero. It is not very uncommon, to hear 
moles, marks, and various other blemishes and malformations as- 
cribed to mental influence. Apprehensions of this kind, sometimes 
seize on the minds of females, with irresistible force; and they often 
occasion great anxiety and unhappiness during gestation. With 
weak, ignorant and superstitious females, every unexpected occur- 
rence, that happens to strike them with sudden alarm, or produces 
any particular excitement of the imagination, is apt to impress 
them with alarming apprehensions, as to the effects it may have on 
the development and conformation of the child in the. womb. These 
distressing illusions are generally much increased by the many 
ridiculous stories of moles and malformations, occasioned in this 
way, which seldom fail to reach the ears of those who are pre- 
disposed to listen to them; for nurses, and gossiping old women, 
are usually furnished with an ample stock of extraordinary exam- 
ples of this kind. The evidences upon which such tales are 
generally founded are never wanting. If a child is born with 
some blemish on its body, the mother is forthwith closely ques- 
tioned as to the circumstances which may have attracted her par- 
ticular attention or excited her mind by sudden surprise or alarm. 
If any thing of this kind is recollected which bears even a remote 
similitude, in colour, shape, or otherwise, to the mark or defect 
observed on the child, it is immediately put down as its indubita- 
ble cause. Sustained by authorities of this kind, these absurd 
apprehensions often acquire an ascendency over the minds of 
pregnant females, which no expostulation or ridicule can entirely 
subdue, and which sometimes give rise to the utmost degree of 
anxiety and distress of mind, and occasionally even to physical 
Buffering and ill-health. 

I do not propose to enter into a formal refutation of this erro- 
neous and injurious notion. It is now unreservedly rejected as the 
fantastic offspring of ignorance and superstition, by all sensible, 



14 OF THE CONDUCT OF MOTHERS 

observant, and reflecting physicians; and it is much to be desired 
that it should be equally repudiated, by those whom it more 
especially concerns, and upon whose happiness and well-being, it 
tends to exercise so injurious an influence. 

But, although the idea that structural blemishes may be pro- 
duced by the influence of the mother's imagination, is wholly 
without foundation, yet it can scarcely be doubted that injurious 
impressions may be made, in an indirect manner, on the child in 
the womb, by affections of the maternal imagination. If intense 
and protracted grief, or violent bursts of passion may exert a 
detrimental influence on the foetus, we may presume that similar 
injurious effects may result from strong affections of the imagination. 
It is well known that disease and even death is sometimes produced 
by intense excitement and concentration of this mental faculty; 
and it is equally notorious that severe and long-standing maladies 
are often effectually removed by its powerful agency. It is evi- 
dent, therefore, that the foetus in utero must be liable to injurious 
impressions from inordinate affections of the maternal imagination; 
for without presuming that the mental affections of the mother 
can exert any direct and immediate impressions on the system of 
the foetus, the diseases and functional disturbances to which the 
mother is liable from influences of this kind, must tend, in some 
degree, to interfere with the regular nourishment and health of the 
child. Every kind of mental excitement, when excessive, may 
prove detrimental to the health, both of the mother and the fcetus; 
and it is probably as important, to guard against the ascendency 
of an excited imagination, as against the various agitating and 
depressing emotions already mentioned. 

IV. Of blood-letting during pregnancy. — Females very generally 
suppose that the condition of pregnancy is, of itself, a sufficient 
reason for blood-letting; and that, although unaccompanied by 
any circumstances, which might be justly deemed an indication, 
for this evacuation, it is necessary, both for the preservation of the 
mother's health, and the safe progress and termination of ges- 
tation. This is a very erroneous opinion, and often leads to 
decidedly prejudicial consequences. Pregnancy is, indeed, gene- 
rally attended with a very peculiar tendency to plethora and 
febrile excitement; and, it may be admitted, that even in a 
state of apparent good health, blood may often be drawn 
during pregnancy with a beneficial result. In such cases how- 
ever, the pulse and other manifestations of general plethora, 
indicate the propriety of depletion; and unless these or some 
other symptoms calling for the abstraction of blood be present, 
it cannot be practised without the risk of unfavourable conse- 
quences. When the symptoms of vascular repletion are not very 
urgent, the plethora may, in general, be much more beneficially 



DURING PREGNANCY. 15 

removed, by using a less nutritious and stimulating diet, than 
by blood-letting. By the former mode, we not only diminish 
the mass of the blood, but we generally also improve the 
condition of the alimentary canal, and thereby contribute sen- 
sibly to the comfort and health of the patient. In weak, 
nervous, and relaxed habits, even where the manifestations 
of vascular fulness are conspicuous, the loss of blood, some- 
times, occasions much debility, and may even contribute to the 
occurrence of abortion. 

Pregnant females should not resort to blood-letting, unless mani- 
fest indications exist for its employment; and, as they cannot 
be competent judges themselves, of the presence or absence of 
such indications, the advice of a physician ought always be pro- 
cured before recourse is had to this measure. To bleed merely 
because pregnancy exists, is a practice which is sanctioned neither 
by reason nor experience, and ought to be discarded as a custom 
calculated to do mischief in some cases at least, whilst it cannot 
do any good, unless called for by other circumstances than the 
condition merely of pregnancy. 

A very severe and troublesome pain is often experienced in the 
right hypochondrium during the latter period of pregnancy; and 
this suffering is, almost always, sought to be mitigated or removed 
by blood-letting. When decided evidences of plethora accompa- 
ny this painful affection, bleeding will occasionally procure con- 
siderable temporary relief; but in the majority of instances, no 
mitigation whatever is obtained from this measure. The relief 
which is sometimes procured by bleeding, is always of short dura- 
tion, the pain usually returning in the course of two or three days; 
and if the bleeding is thus frequently repeated, as is sometimes 
done, much mischief is apt to be produced, by the general debility 
and languor which it tends to occasion. When the symptoms of 
vascular turgescence throughout the system are conspicuous in 
connection with this pain in the side, it will certainly be proper to 
diminish the mass of the circulating fluid by venesection ; but where 
no indications of this kind are present, blood ought not to be 
abstracted merely on account of this affection; for it will most 
assuredly fail of procuring the desired relief; and may, when not 
particularly called for, operate unfavourably on the general health 
of the patient. Moderation in diet, together with a proper atten- 
tion to the state of the bowels, and the use of gentle exercise by 
walking, will, in general, do much more towards the removal of 
this source of uneasiness and suffering, than will result from blood- 
letting, where this evacuation is not especially indicated by the 
fulness and firmness of the pulse, or by other manifestations of 
general vascular plethora. 



16 OF THE CONDUCT OF MOTHERS 

The breasts and nipples should be particularly attended to during 
the latter months of gestation, in order to prepare them for the 
important function of suckling the infant. To prevent the nipples 
from becoming excoriated and inflamed, in consequence of the 
irritation occasioned by the child's lips and tongue, in the act of 
sucking, means should be used, some weeks before the expected 
termination of gestation, to render them firm and to diminish their 
sensibility to irritating impressions. For this purpose the nipples 
should be daily washed with luke warm water, then dried by ex- 
posing them to the free air, and afterwards gently rubbed for five 
or six minutes with a soft piece of flannel or with the extremities 
of the fingers. Much benefit may also be obtained, from the oc- 
casional application of a pup to the breasts during the last four or 
five weeks of gestation. Washing the nipples with brandy and 
water, and with various stimulating lotions is a very common 
practice; and where the skin of the nipples is very delicate and 
sensible, considerable benefit may, at times, be derived from such 
applications. Dr. Dev/ees, however, is decidedly opposed to the 
use of astringent washes, for the purpose of preparing the nipples. 
My own experience, does not lead me to apprehend any detriment 
from certain applications of this kind; on the contrary, I have 
been constantly in the habit of directing the use of a wash, com- 
posed of two drachms of the tincture of myrhh diluted with two 
ounces of water, with a drachm of laudanum; and in general the 
effects have been manifestly advantageous. The nipples should 
first be bathed in luke warm water, so as to soften and separate the 
indurated cuticle, then dried, and gently rubbed with soft flannel, 
as has just been stated, and afterwards washed with the lotion just 
mentioned. If this course is pursued daily, for several weeks 
previous to the birth of the child, it will, in general, obviate all 
difficulties in this respect. Compression of the breasts by corsets, 
tight jackets, and stays, during pregnancy, is calculated to inter- 
fere very materially with the function of lactation. The almost 
constant pressure which is thus made on the nipples, forces them 
inwards, and frequently buries them in the yielding substance of 
the breasts, so as to render suckling very difficult, and often wholly 
impracticable. The full and regular development of the mamma- 
ry glands too, is doubtless much impeded by the pressure which 
they suffer in this way. It is well known that compression is a 
very powerful means for promoting absorption; and surgeons 
often avail themselves of this measure, for reducing glandular and 
other enlargements on the external parts of the body. We could 
indeed scarcely adopt more effectual means for restraining the 
natural growth and development of the breasts than tightly laced 
jackets, stays, and corsets; and it is, doubtless, to this circumstance 
that we must ascribe the flat and unfeminine breasts which are so 



OF THE MANAGEMENT OF NEW-BORN INFANTS, 17 

common among the young females of the present day. I have 
been frequently struck with the fact, that in the country, and 
among the lower classes of females, who do not compress their 
chests, by corsets, &c. we generally find a much greater propor- 
tion of full and well developed bosoms than in cities and among 
fashionable ladies. 

When the nipples are very small or have been forced inwards 
by the pressure of corsets, &c, they should be drawn out by 
means of a suction pump, or with a tobacco pipe, and all undue 
compression of the breasts carefully avoided. One of the white 
earthen tobacco pipes, with a large bowl will in general answer 
this purpose very well. The effort of drawing the nipples out, 
should be repeated several times daily, until they have acquired a 
degree of prominency which will enable the child to lay hold 
of them without difficulty. 



CHAPTER II. 

OF THE MANAGEMENT OF NEW-BORN INFANTS. 

The proper management and nursing of the infant during the 
first few weeks after its birth, has a most important influence on 
its future well-being. Previous to its entrance into independent 
life, the child enjoys a tranquil state of vegetative existence, 
removed from the multifarious influences of external causes, with 
but a narrow circle of organic actions to perform, and its sensorial 
functions in a state of total inactivity. How great the change 
which takes place at birth! In a moment, a multitude of new 
and highly important relations, are established between its tender 
and uninured organization, and the countless objects of external 
nature. Functions and operations which, up to this period, lay 
passive and dormant, are now suddenly called into action ; and the 
whole machinery of its system, starts forth in the performances 
of the harmonious series of vital actions. The air for the first 
time, comes in contact with its body — it rushes into the cells of 
the lungs, and respiration is established; the current of the circu- 
lation finds new channels, and abandons those which were pre- 
viously the principal conduits of the vital fluid. The senses are 
awakened, light strikes the eyes, sound the ears, and its taste is 
delighted with the simple nourishment, formed for it, in the 
D 



18 OF THE MANAGEMENT 

maternal bosom; the sense of touch is acute, it feels the variations 
of temperature, and is keenly susceptible of pain from injurious im- 
pressions, and gratification from soothing and agreeable influences. 
The stomach begins to exercise its instinctive calls for nourish- 
ment; urine is secreted, the bowels begin to act, and to eliminate 
their fecal contents, and the various secretions subservient to 
digestion areestablished. When we contemplate this remarkable 
transition of a most helpless and feeble being, from a state of 
repose and almost total exemption from external impressions, to a 
mode of existence which subjects its tender and uninured organi- 
zation to the ceaseless influence of a vast multitude of varying 
agencies, it would seem truly surprizing, that the new-born infant 
could prolong its existence, even for a few hours, did we not know 
that the benovolent author of nature, has endowed every being, 
with powers adequate, under ordinary circumstances, to sustain 
the changes and modifications which it is destined to undergo in 
the progress of its development from the nascent point, to the full 
state of adult life. It is evident, however, that this power of 
accommodation can afford no protection against the numberless 
accidental and unnatural impressions which the new-born infant 
is liable to suffer; on the contrary, there is no period of life, in 
which there exists so great a susceptibility to injurious influences, 
as during the early stages of infancy. Apparently slight errors 
during the first few weeks after birth, often lay the foundation of 
permanent constitutional infirmity; and much suffering or early 
death, is but too common a consequence of improper management 
in relation particularly to the diet, dress, and exposure of the new- 
born infant. 

I. Of the washing and dressing of the new-born infant. — When 
the infant is born, and the function of breathing is well established, 
it must be carefully separated from the mother and secundines 
wrapped up in a piece of soft flannel and handed to the nurse. 
If the child breathes feebly and imperfectly, or exhibits other 
signs of great feebleness it should not be washed immediately, but 
suffered to remain as quiet and undisturbed as possible, until the 
vital actions have assumed some degree of activity. When on 
the contrary it manifests an active state of the vital powers, the 
washing should be performed as soon as convenient after its sepa- 
ration from the mother. It is of importance that this duty should 
be carefully and thoroughly executed. The white caseous sub- 
stance which is deposited on the surface of the foetus, during its 
sojourn in the womb, adheres very closely to the skin; and as it 
is wholly insoluble in water, and but very slightly acted on by 
soap, it can never be sufficiently removed, unless some other sub- 
stance is employed which has the property of rendering it soluble. 
For this purpose, lard, or fresh butter, or the yolk of eggs may be 



OF NEW-BORN INFANTS. 19 

used. Before any water is applied to the child's body, the skin 
should be smeared and gently rubbed with one of these substances; 
after which the whole may be readily washed off with warm 
water and soap. Dr. Dewees advises that the finest soap should 
be selected, for the stronger soaps, particularly " the brown and 
stimulating soap, called resin soap" is apt to irritate and inflame 
the tender skin of the infant, and to give rise to painful and pro- 
tracted abrasions of the cuticle. When the yolk of eggs is used 
for this purpose, soap is altogether unnecessary, simple warm 
water being sufficient to cleanse the surface thoroughly. It has 
been much disputed whether warm or cold water is most proper 
for the first ablutions of the infant. Under an impression that the 
use of cold water is calculated to invigorate the infant, and to 
inure it early to vicissitudes of atmospheric temperature, and thus 
to obviate, to a degree, the liability to disease from this source, 
many physicians have strenuously insisted on the superiority of 
cold over warm water for this purpose. Although there may ap- 
pear to be some justice in these views, yet general experience is 
at present decidedly in favour of the employment of warm water 
for washing infants; and a correct view of the circumstances con- 
nected with this subject, gives it also, the decisive sanction of 
reason and common sense. The infant having never experienced 
but one uniform degree of temperature, during the whole period 
of its uterine existence, cannot but receive a painful and often 
injurious shock when suddenly subjected to the application of cold 
water; and it cannot be doubted, that the immediate exposure 
of new-born children to cold air or water is frequently produc- 
tive of serious maladies. Were an adult confined for nine months 
to an invariable temparature of 98°, and then suddenly ushered 
into a medium of the temperature of 60°, is it not extremely pro- 
bable that it would prove highly detrimental to his health? The 
occurrence of disease from much less remarkable vicissitudes than 
the one just supposed, is a matter of almost daily experience. 
How then can it be reasonably contended that the delicate, 
feeble, and uninured organization of the new-born babe, should 
be capable of bearing such a transition without experiencing any 
injurious impressions. Indeed, the struggles, the pale and con- 
tracted skin, the shrieks, and the trembling which we often wit- 
ness when the infant is plunged or washed in cold water, afford 
sufficient evidence that painful, and we may presume, injurious im- 
pressions are made on its system. The propriety of using warm 
water is particularly urgent when the infant is feeble. Doubtless, 
with robust and vigorous infants, a salutary reaction often speedi- 
ly takes place, under the depressing influence of cold ablutions; 
but where the vital energies are feeble, the reaction may fail, and 
a degree of depression be produced, which may place the life of 



20 OF THE MANAGEMENT 

the infant in imminent danger. Instead of abstracting heat, we 
find it much more congenial to the infanticile system to impart 
a moderate degree of warmth from without: and with very deli- 
cate and feeble infants the constant application of a comfortable 
degree of warmth is particularly important. The water used for 
washing healthy and vigorous infants should be luke-warm; but 
for such as are weak, water of a higher temperature will be 
proper, and in cases of extreme feebleness, a small portion of wine 
may be advantageously added to the water. To remove the 
unctuous matter already mentioned, a fine and soft cotton or 
flannel rag should be used for washing. This peculiar substance 
is in general, most abundant in the folds of the joints, particularly 
in the groins, and armpits; and it is particularly important to the 
health and comfort of the child, that every particle of it should 
be removed from these and other parts of its body. It is some- 
times impracticable to remove the whole of this matter from the 
folds of the skin and joints at the first washing, without causing 
too much irritation by the rubbing, which it is necessary to use 
to detach it entirely from the skin. When this is the case, the 
portion that remains may be removed at the second washing. 

Many are in the habit of bathing the head of the new-born 
infant, with brandy or some other spirituous liquor, in order as is 
imagined, to invigorate its system and fortify it against the inju- 
rious effects of cold and other causes of disease. This practice 
can serve no useful purpose; and as it may do mischief by over- 
exciting the system as well as by causing pain and inflammation 
of the eyes, it ought to be abandoned. When the infant is very 
feeble and languid, a small portion of some stimulating liquor 
may be added to the "»vater in which it is washed ; but unless such 
a special reason for stimulating applications be present, plain 
water is decidedly the most proper. After the child has been tho- 
roughly washed, it should be well dried, and immediately dressed. 
Throughout the whole period of infancy the utmost attention 
should be paid to keeping the child's body in a state of perfect 
cleanliness. The ablutions should be performed every morning 
and evening, though in the evening, the lower half of the body 
only need be washed. It is also a matter of very great conse- 
quence to the comfort and health of the infant to keep every part 
of its body dry. This is particularly important with those parts 
which are subject to friction, from being in contact with each 
other; as the nates, the armpits, groin, folds of the neck, &c. 
Excoriations and painful inflammations are apt to occur in these 
situations, when they are suffered to remain wet or moist. The 
common practice of dusting fine starch or hair-powder over the 
body, with the view of keeping the skin dry and soft, is im- 
proper, and ought not to be adopted. It interferes with the 



OF NEW-BORN INFANTS. 21 

regular transpiration of the skin, and has a tendency to give rise 
to a troublesome itching and harshness of the cuticle. On the ap- 
pearance, however, of slight excoriations, a little hair-powder, or 
prepared tuttia may be dusted on the parts with benefit; but it 
cannot be used with advantage as a preventive of such affections. 

II. Of the dress of the child. — The first thing to be done in 
dressing the infant, is to fix the remains of the navel string by 
surrounding it with a piece of soft dry rag, and supporting it in a 
proper position, by means of a roller or bandage, passed round the 
child's body. A simple strip of flannel, about four inches wide, 
is the best material for this purpose. Particular care must be 
taken not to draw this bandage too tight round the abdomen. It 
should be sufficiently loose to admit of the easy introduction of a 
finger under it. If it embraces the body too closely, it occasions 
uneasiness, pain, and difficulty of breathing, by impeding the co- 
operation of the abdominal muscles, and the free descent of the 
diaphragm; at the same time that it tends, very strongly, to favour 
the occurrence of umbilical, and particularly scrotal hernia in 
male infants, by its necessary effect of compressing the abdominal 
cavity, which, with the forcible descent of the diaphragm in the 
act of crying, coughing, and straining, presses the viscera down, 
and forces them through the natural openings into the abdominal 
parietes. I have repeatedly known inguinal rupture produced in 
this way. The bandage should be worn four or five months be- 
fore it is laid aside; and where the parts about the navel appear 
to be weak and ready to yield to the pressure of the viscera, it 
will be proper to continue the use of the bandage a much longer 
period. Previous to the separation of the remaining piece of 
navel-string, care must be taken not to pull it; and the parts about 
the navel should be kept as dry and clean as possible. A neglect 
in these particulars, is apt to give rise to painful inflammation and 
excoriation of the umbilicus. " Sometimes the vessels of the um- 
bilical cord, which before were distended with blood, will collapse, 
the bandage become loose, and the life of the babe be endangered 
by excessive bleeding; the state of the bandage must therefore, 
from time to time, be carefully examined." 

With regard to the clothing of infants, it may be observed, in a 
general way, that it should be warm, light, and loose. It is 
scarcely necessary, to say any thing, in reprobration of the old, 
absurd, and injurious practice of swaddling infants. This cruel 
custom is now universally abandoned by every civilized people; 
and it is surprising that the common sense and humanity of man- 
kind, should have ever permitted its introduction. To confine and 
restrain every member and almost every muscle of the body 
in this manner, during the fragile state of infancy, must be as 
detrimental to the health and regular developement of the child, 
as it is cruel and barbarous. 



22 OF THE MANAGEMENT 

The clothing of infants should be managed in such a way, as to 
protect them against the effects of too high or low a temperature, 
and against sudden alterations of the air and weather. In the 
winter, or during cool seasons, flannel forms an essential part of 
the clothing. The lightest and softest kinds of flannel should 
be selected. In new-born infants of a feeble and languid habit, 
the use of flannel next the skin, is particularly useful. During 
the first few months after birth, warmth is always peculiarly con- 
genial to the infantile system; and where from feebleness, the 
developement of the animal temperature is not very rapid, it is 
particularly necessary to use flannel clothing, so as to favour the 
accumulation of warmth in the child's body. Besides the useful- 
ness of flannel as a means for obviating the depressing and 
injurious effects of cold and atmospheric vicissitudes, benefit may 
also result from its gentle stimulating impressions on the surface 
of the body, by which the blood is solicited to the external capilla- 
ries and unfavourable congestions obviated in the internal organs. 
During the warm seasons, the flannel should be substituted by 
muslin; but the moment that any sudden reduction of the atmos- 
pheric temperature takes place, the use of the flannel should be 
resumed. Common sense indeed, dictates the propriety of con- 
stantly accommodating the clothing to the varying states of the 
weather, and when this obvious duty is not attended to, much 
disease and suffering is liable to occur, which under a more pru- 
dent management in this respect, would be prevented. In the 
summer season, infants are often exposed to unpleasant conse- 
quences from being too thickly and warmly covered while sleep- 
ing. The infant with its usual quantity of clothing, is often laid 
on a bed of feathers or down, into which its body sinks, and a thick 
cover thrown over it; from which it is generally taken up when 
it awakes, bathed in a copious perspiration and of course par- 
ticularly predisposed to receive injury, should it happen to be 
immediately exposed to a current of fresh and cool air. There 
can be no doubt that catarrhal and bowel complaints are fre- 
quently produced in this way. I have known a case of fatal 
cynanche trachealis speedily excited by carrying a child, taken 
out of its cradle, in a state of free perspiration, into a draught of 
cool air. It is proper to observe, that the child should never be 
suffered to sleep in the flannel which has been worn during the 
da} r and in the morning it must again be changed. 

During the first eight or nine months, the child's clothes should 
be long enough, to extend considerably beyond the feet, in order 
that the lower parts of the body may be duly protected, against 
the effects of cold and the variations of temperature. After this 
age, however, the feet should be entirely unincumbered by the 
clothing, so as to permit the free motion of the inferior extremi- 



OF NEW-BORN INFANTS. 23 

ties. During cold weather, fine woollen stockings, sufficiently 
wide to be easily put on and to prevent every degree of compres- 
sion, should be worn; but in warm weather light and soft flannel 
socks will suffice. The shoes should be made of light and pliable 
materials, and sufficiently large to prevent all constraint of the 
feet. Some writers object to putting shoes on infants. It is 
alleged that they tend to cramp the feet and restrain their free 
motion, and that consequently the child " does not learn to walk 
so early, as when the feet are unincumbered by shoes." These 
objections, however, may be obviated, "by having the shoes made 
large and of the most pliant materials;" and I fully accord with 
Dr. Dewees in the opinion, " that as shoes afford protection from 
cold, and security against accident when the child is placed upon 
the floor, especially on carpeted floors, where pins, needles, 
and other sharp substances, are often concealed, they can not, 
with perfect propriety, be dispensed with." The use of shoes is 
decidedly proper when the child is carried out of doors during 
cold weather. In very young infants, thin woollen socks will 
protect the feet sufficiently during the warm seasons; but when 
they are about learning to walk, it is best, for the reason just 
quoted, to have the feet invested in shoes made of very soft and 
light materials. 

It is highly important that the child should be kept as dry as 
possible. Wet diapers or stockings, when suffered to remain on 
the child for some time, are apt to give rise to bowel complaints 
and febrile affections, more especially during the cold seasons. 
They tend moreover very strongly to favour the occurrence of ex- 
coriations, and painful irritations of the skin about the groin and 
nates. The under-clothes of the child should be frequently 
examined, and if any part is found to be wet, it should be imme- 
diately removed and substituted by a dry and clean one. 

In dressing children there ought to be as few pins used as 
may be practicable, for the proper adjustment of the clothes. 
Children are frequently much injured by the points of pins being 
accidentally directed inwards in handling them, or by their own 
movements. I have witnessed several instances of very unpleasant 
consequences from this source; and the instances of slight but 
painful punctures and scratches from pins used in the dress of 
infants are very common. Tapes and strings should therefore be 
used instead of pins, whenever they can be made to answer the 
purpose. If pins are used at all, the larger kind should always 
be selected; for the small pins now in general use, are much more 
apt to slip through the clothes and consequently to wound the 
skin than the larger kind (Dewees). 

Before leaving this subject it will be proper to say something 
concerning the usual mode of dressing children, so as to leave the 



24 OF THE MANAGEMENT 

neck, upper part of the chest, and forearms perfectly bare. 
Whilst adults are careful to keep these parts well covered and 
protected against the influence of cold, children are almost uni- 
versally suffered to be without such protection; and the nudity 
of the neck and arms is generally continued, until they are four or 
five years old. It has been supposed that this custom is one of 
the principal reasons why inflammatory affections of the respira- 
tory organs are so much more common during the period of child- 
hood, than at a more advanced age; and there can be no doubt 
that its influence, in this respect, is very considerable. Nothing 
is more common than to see children out of doors, with the arms 
and upper parts of the chest, completely exposed, even in damp 
and cold weather; and it cannot be believed that such exposure is 
unattended with risk of injurious consequences. Croup, inflam- 
mation of the lungs, catarrh, and general fever are doubtless fre- 
quently the consequences of this irrational custom; and it is not 
improbable that the foundation of pulmonary consumption is often 
thus laid, during the first few years of life. This custom, there- 
fore, ought to be abandoned, as one of a decidedly injurious 
tendency, more especially during the cold and variable seasons. 
During the warm months of summer, the arms, and neck may be 
left bare, without any particular liability to injurious consequences; 
but every part of the chest should at all times be protected with 
suitable clothing. It is generally supposed that the usual mode 
of dressing children, is calculated to inure them to the impressions 
of cold, and to obviate the liability to disease from this cause. 
Doubtless this may be the result with those who survive the ex- 
periment; but before the system is thus inured, the child may be 
carried off" by some inflammatory affection, produced by such ex- 
posure. It is certainly a most inconsistent practice to expose the 
breast and arms during the weak and tender age of childhood, 
and yet to deem it necessary to keep these parts carefully covered 
after the system has acquired firmness and its full powers of vital 
resistance by a more mature age. 

The universal custom of covering the infant's head with a cap, 
is of very doubtful propriety. There is naturally a strong tendency 
to a preternatural determination of blood to the head during in- 
fancy; and the predisposition to inflammatory diseases of the 
head, is confessedly, much greater during this early age, than at 
any other period of life. If the rule to " keep the head cool," is 
ever applicable, it is particularly so during infancy. In cold and 
damp weather, a very thin and light hat may be proper; but 
during the warm seasons, it will be conducive to the child's com- 
fort and health to suffer the head to be wholly uncovered- and 
even in winter, if the child's head is well covered with hair^ and 
it be confined within doors, caps may be very prudently dis- 
pensed with. 



OF THE NOURISHMENT OF INFANTS. 25 



CHAPTER III. 

OF THE NOURISHMENT OF INFANTS. 

There is probably no single source of disease, during the first 
few years of life, whose influence is so extensive and destructive, 
as improper management in relation to the diet. The foundation 
of irremediable chronic diseases, and of constitutional infirmity, 
throughout the subsequent period of life, is often laid within the 
first month, or even first few days after birth, by errors of this 
kind ; and a great amount of the suffering and mortality which 
occurs during infancy, must be ascribed to the same prevailing 
source of injury and disorder. The almost universal custom of 
feeding children with inappropriate articles of food, very soon after 
birth, is extremely reprehensible. No sooner is the infant washed 
and dressed, than the nurse is ready with her spoon and cup of 
gruel, pulverized crackers dissolved in water, or some such prepa- 
ration, to fill its stomach to the utmost of its capacity; and this 
process of stuffing is continued with a ruinous degree of diligence 
and perseverance. The tender and uninured digestive organs 
of the new-born babe are thus often seriously injured during the 
first twenty-four hours. Nature herself seems to point out the 
impropriety of this practice. She withholds the nourishment 
which she provides, until many hours after birth. It seems highly 
improbable, if it were necessary that the infant should receive 
nourishment soon after birth, that the appropriate alimentary 
fluid should be so tardily furnished. We no where find such an 
inconsistency in nature. It is true, indeed, that the secretion of 
milk in the maternal breasts is often delayed a much longer pe- 
riod, than it would be prudent to withhold nourishment from the 
infant. Still we perceive, in this arrangement, that aliment is 
not necessary to the welfare of the child very soon after its birth. 
It cannot be presumed that the activity of the digestive organs, 
and a demand by them for nourishment is immediately awakened, 
on the child's entrance into the world. We no where see a 
physical want established without the appropriate means being 
furnished for satisfying it. I do not indeed, mean to inculcate, 
that nourishment is to be entirely withheld from the infant until 
the milk is secreted; but I am persuaded, that with healthy infants, 
E 



26 OF THE NOURISHMENT 

several hours, at least, should be suffered to pass immediately after 
birth before any alimentary substances are introduced into its 
stomach; and I would most strenuously insist on the importance 
of exhibiting but small portions at a time, and at such intervals, as 
will obviate all risk of overloading or distending the stomach. This 
latter error is the most to be deprecated. A few tea-spoonfuls of 
some very bland and weak fluid, could not be deemed detrimental, 
though given immediately afterbirth; but the usual practice of fil- 
ing the stomach to overflowing, and keeping it in this state of ful- 
ness and distention, is most ruinous to the health and comfort of the 
child. At every period of life over-distention of the stomach, by 
food or drink, is one of the most certain and powerful causes of 
indigestion; and we can scarcely conceive it possible, that the 
tender and uninured stomach of the new-born infant, can escape 
serious debility and irritation, when early overcharged with food 
even of the mildest kind. The digestive powers of the stomachbeing 
thus prostrated or enfeebled, all the harassing and painfal conse- 
quences of indigestion ensue. Acidity, flatulency, colic, diarrhoea, 
vomiting, green and griping stools, emaciation, not to mention 
other distressing and dangerous symptoms inevitably supervene. 
In nine cases out often, perhaps, the griping, flatulency, diarrhoea, 
and colic which so frequently harass infants, during the first half 
year after birth, are the results of indigestion, brought on by errors 
in diet. Not unfrequentfy the digestive powers are effectively 
prostrated by the first feeding. Conceiving that, as the child has 
been fasting during the long period of nine months, it must needs 
come into the world with an excellent appetite, and an imme- 
diate demand for nourishment, ignorant nurses — (and the ignorant 
are incomparably most numerous) deem it their duty, to be most 
vigilant and industrious in charging the infant's stomach with some 
alimentary substance — often extremely inappropriate. To relieve 
the colic, griping, flatulency, diarrhoea, &c. which ensue, recourse 
is had to cat-mint tea, anniseed tea, Godfrey's cordial, paragoric, 
or some other palliative or nostrum, and thus an additional source 
of gastric derangement or indigestion is brought into operation. 
The screams and restlessness of the infant occasioned by the 
griping and colic, are frequently regarded as manifestations of 
hunger. To appease this supposed craving, the stomach is almost 
constantly kept in a state of distention with food; and thus the 
helpless babe has no chance of escaping from the torments and 
ruinous consequences of its unfortunate condition. Very vigorous 
and healthy infants often pass through the gastric irritation and dis- 
tress produced by improper nourishment soon after birth, without 
sustaining any permanent injury in health or constitutional infir- 
mity. After four or five months of flatulency, griping, &c, the 
digestive organs gradually become inured to the impressions of the 



OF INFANTS. 27 

food, and a considerable degree of health is obtained. In many 
cases, however, the irritation which is thus kept up in the stom- 
ach and bowels, does not pass off in so favourable a manner. — 
Jaundice, chronic and unmanageable diarrhoea, emaciation, slow 
fever, enlarged mesenteric glands, dropsy in the brain, scrofula, 
chronic affections of the liver, epilepsy, and other dangerous ma- 
ladies, may, and not unfrequently do, result from this state of the 
alimentary canal, during infancy. Great distress and suffering, 
are sometimes witnessed during the early period of infancy, from 
indigestion, and consequent gastro-intestinal irritation, even where 
the child is wholly nourished by the breast. For when, during 
the time which intervenes between the secretion of milk, and the 
birth of the child, crude articles of nourishment are superabun- 
dantly introduced into the infant's stomach, the digestive functions 
are often, at once, so deranged and impaired, that even the 
wholesome and congenial fluid furnished by the maternal breasts, 
will not be easily digested; and acidity, flatulency and colic will 
continue to harass the child, until the digestive powers gradually 
acquire a greater degree of vigour. 

That the jaundice of infants is generally produced by dispep- 
tic irritation, I have not the slightest doubt. Mucous irritation 
of the duodenum, is now well known to be an active and fre- 
quent source of this malady; and this affection is very rarely 
found to occur in new-born infants without being preceded by 
decided manifestations of irritation of the digestive organs. Let 
the child's stomach be once or twice filled during the first twenty- 
four hours with gruel, or any of the ordinary preparations em- 
ployed by nurses for this purpose, and the chances will probably 
be as ten to one, that acidity, vomiting, colic, griping, and jaun- 
dice will supervene. There is assuredly no period throughout 
the whole course of life, in which the observance of caution, in 
relation to the ingesta is of greater moment than in the compara- 
tively short interval which passes between the birth of the infant, 
and the secretion of its natural aliment. If the powers of the 
stomach are not prostrated during this short interval, which by 
the customary mode of management is seldom avoided, and the 
child is fortunate enough to be nourished by its mother's milk, 
the ordinary gastric disturbances of infancy will rarely super- 
vene. Alimentary ingesta, are not, however, the only sources 
of direct gastric irritation and indigestion at this early period of 
life. Much mischief is, doubtless, often done, by the means em- 
ployed for removing the meconium. Active purgatives are some- 
times given for this purpose; and there is much reason for belie- 
ving that the infant's digestive functions are often injured in this 
manner. I have hitherto dwelled especially on the importance 
of withholding nourishment from the child, immediately after 



28 OF THE NOURISHMENT 

birth, and before milk is furnished by the maternal breast. I am 
induced to be the more urgent on this point, because many who 
would not think of feeding the child, after the breasts supply a 
sufficient quantity of the appropriate nourishment, consider it ne- 
cessary to do so before the milk is secreted, lest it may suffer 
from want of nourishment. I have already stated that there can 
be no objection to the exhibition of small portions of some very 
mild and simple fluid to the infant, previous to its receiving nour- 
ishment from the breast; and when the secretion of milk is consi- 
derably delayed, this measure will even be proper. A mixture 
of two parts of fresh cow's-milk, and one part of warm water ap- 
proaches nearer to the nature of human milk than any thing else 
that can be conveniently procured. Of this a few teaspoonfuls 
may be given from time to time, carefully avoiding overcharging 
the stomach, until the mother's breasts are ready to yield their 
more congenial nutriment. In order to excite the early secretion 
of milk, it will be proper to let the child draw the breasts, for a 
few minutes, soon after the mother is comfortably fixed in bed, 
provided her health and strength will admit of it. After the se- 
cretion of milk is once fully established, and furnished in sufficient 
quantity, the infant should be nourished exclusively by the breast. 
Not even the mild and simple fluid just mentioned should be al- 
lowed, unless some special reason exist for the use of additional 
nourishment. It seldom occurs in healthy mothers, that the 
quantity of milk supplied by the breast is not sufficient to afford 
adequate nourishment to the child for the first two or three 
months, and in general much longer, without the necessity of any 
additional artificial food. Should it be otherwise, however, or 
should there be an inability of suckling the child, in consequence 
of the mother's ill-health, or disease of the breasts, the mixture 
of milk and water mentioned above, should constitute the sole 
aliment, until the primary teeth make their appearance; or what 
is still more suitable, a healthy and fresh wet-nurse should be 
procured. 

There is no substance in nature, nor can there be any thing 
prepared by art, which forms so congenial and wholesome a nou- 
rishment, during the early period of infancy, as the human milk. 
"When it is supplied in sufficient quantity, no other alimentary 
substance ought to be given, during the first three or four months 
after birth. It seems, almost superfluous to remark that nature 
manifestly intended this fluid, as the sole nutriment at this early 
stage of life. Throughout the whole range of the higher orders 
of animated beings, the structure of the mouth, particularly in 
relation to the absence or presence of teeth — their conformation, 
position and situation, — furnishes unequivocal indications, as to 
the kind of food most appropriate and salutary. The same re- 



OF INFANTS. 29 

lation between the condition of the mouth, in this respect, and 
the kind of aliment best adapted to the welfare of the system, 
occurs during infancy; and an attention to this circumstance, 
affords a good general index, as to the kind of diet best suited to 
the new-born infant, and the changes which it will be proper to 
make according as it advances in age. The infant comes into 
the world with soft and toothless gums, — full and prominent lips, 
and an instinctive ability and readiness to grasp the nipple with 
its tongue and lips, and to perform the actions of suction in the 
most perfect manner. For a considerable time it remains wholly 
incapable of performing the motions of mastication. It is evi- 
dently the design of nature, that the infant shall obtain its nutri- 
ment by suction-, and as the maternal breasts with their grateful 
and congenial lacteous fluid, correspond with this arrangement 
and intention of nature, it is manifest, that these constitute the 
only natural and truly appropriate source of nourishment during 
early infancy. 

The infant should be nourished exclusively by the breast, until 
the first teeth make their appearance. No other kind of nou- 
rishment whatever, should be allowed, anterior to this period, 
unless from deficiency of milk or some other cause, the use of ad- 
ditional aliment becomes necessary. After the first teeth have 
come out, small portions of barley-water, thinly prepared arrow- 
root, or a mixture of equal parts of cow's-milk and water, may be 
given two or three times daily, in addition to the nourishment 
drawn from the breasts. I do not mean to say, that when the 
child arrives at this stage, it becomes necessary, or even deci- 
dedly proper, as a general rule, to exhibit any additional articles 
of food. In general, however, the simple and mild liquids, just 
mentioned, may be given at this period, with very little risk of 
unpleasant consequences; for the digestive organs have, by this 
time, acquired a degree of power and activity sufficient to obvi- 
ate the painful and disturbing effects which would arise from the 
use of such food during the first four or five weeks after birth. 
I have very rarely known any ill consequences to occur, from the 
moderate use of the articles of nourishment just mentioned, at 
this period of infancy; and I am satisfied, that when the breasts 
do not furnish a sufficiently copious supply of milk, they may, in 
general, be resorted to, with perfect propriety. It is particularly 
important however, when additional aliment is used, to avoid 
overloading the stomach; for over-distention, seldom fails to im- 
pair the tone of the stomach, and to give rise to dyspeptic distur- 
bances. It is also of much consequence that the food should be 
introduced into the stomach, as gradually as practicable. In 
suckling the child receives its nourishment very gradually; and 
this should be imitated, when artificial food is given by the hand. 



30 OF THE NOURISHMENT 

This can be most conveniently done by causing the infant to 
suck the fluid aliment from a bottle, furnished with the usual 
silver tube, the mouth-piece of which is pierced with a small 
orifice. By this contrivance, the child will receive its food in 
the same gradual manner, as when nourished at the breast, and 
it will rarely take more than its appetite calls for, an error which 
is frequently committed when fed with a spoon. After the se- 
venth month, small portions of the preparations of food just men- 
tioned, should be given at regular periods, three or four times 
daily. This will prepare the infant, for the sudden change, 
which it has to undergo in the character of its food, when it is 
weaned; and thereby tend to lessen the liability to unpleasant 
consequences from the change. Infants who have been mode- 
rately fed with suitable articles of food, sometime previous to 
weaning, almost always accommodate themselves much more 
readily and with much less uneasiness to the change, than such 
as have seldom or never received any other aliment, than that 
which they draw from the mother's or nurse's breasts. 

If the appointments of nature, and experience shew that human 
milk is the appropriate aliment during infancy, it is manifest that 
the mother's breasts constitute the only genuine fountain from 
which this delicious and congenial nutriment is to be drawn by 
the infant. Mothers ought never to delegate the suckling of 
their infants to others. This sacred office should rest with the 
mother alone. It is an irremissible duty, which can never be ne- 
glected or put off, without contravening the wise and benevolent 
arrangements of Providence. The mother who submits the suck- 
ling of her infant to another, while her own breasts are ready to 
furnish an ample supply of milk, can scarcely possess an amiable 
and moral heart. It is indeed a most extraordinary circumstance, 
that a duty which is so strongly enforced by the commands of 
nature, and which is connected with so many delightful and hal- 
lowed sentiments of the maternal heart, should ever be volunta- 
rily relinquished. Did we notice this unnatural and cruel prac- 
tice only among the low and ignorant, we might ascribe it to that 
blunted sensibility and obtuse moral feeling which is apt to be 
engendered by the privations and hardships of poverty. But it 
is not so. It is only among educated, refined and polished fe- 
males, that we witness the appointments of nature, and the 
decencies of maternal conduct thus outraged. It would seem as 
if the higher refinements of civilization tended rather to stifle, 
than to cherish the pure and instinctive sentiments of the heart, 
and to substitute the dictates of fashion for the original and uner- 
ring impulses of nature. 

As it is manifestly the design of nature, that the infant should 
draw its food from the mother's breasts, it is reasonable to pre- 



OF INFANTS. 31 

sume that this design cannot be contravened, without subjecting 
both mother and infant, to an increased liability to injurious con- 
sequences. It can scarcely be doubted that the mother's milk, is, 
in general, better adapted to the constitutional temperament of 
her offspring, than that furnished by others. Besides, when the 
suckling of the infant is submitted to a nurse, it is liable to vari- 
ous sources of injury and disorder, which are in a great degree, if 
not entirely obviated, when this important duty is performed by 
the mother. The nurse may not be able to furnish a sufficient 
supply of milk to afford adequate nourishment to the infant. This 
is by no means uncommon. Nurses often practise great deception 
in this respect. In order to obtain employment, or retain their 
situation, they will declare that they have an abundance of milk, 
when, in truth, the very reverse is the case. To supply this de- 
ficiency of milk, the wily nurse will resort to clandestine feeding; 
and as this is generally done in a very improper way, the child 
usually fares much worse, than if it had been, from the beginning, 
nursed exclusively by appropriate artificial food. The food which 
is thus secretly hurried into the stomach of the child, never fails 
to give rise to griping, flatulency, colic, diarrhoea, and fretfulness. 
To allay these sufferings, carminatives and anodynes are privately 
resorted to; and thus, whilst the parents suppose that the infant 
enjoys the advantage of proper nursing, its health, and even life 
are often sacrificed to the secret practices of a mercenary and 
unprincipled nurse. 

The child, also, runs much more risk of receiving bad and 
unwholesome milk, when suckled by a hired nurse, than when 
this office is performed by the mother herself. I have known 
several instances of most serious injury inflicted on the child's 
health and constitution in this way. That syphilis may be, and 
has been communicated through the milk of the nurse, I have not 
the smallest doubt; and the communication of other loathsome 
diseases, by nurses, to their nurslings, such as itch, tetter, &c, is 
by no means uncommon. But even where no specific disease of 
this kind, is contracted, the general health and constitution are 
often permanently injured by the unwholesome or uncongenial 
character of the milk furnished by the nurse. When the milk 
of the nurse is of a bad quality, it usually produces very obvious 
disturbances in the digestive organs of the infant. The stomach 
and bowels become weak and irritable. The child vomits fre- 
quently, or is harassed by painful and watery diarrhoea. It becomes 
restless, fretful, and peevish; its flesh wastes and becomes flabby; 
its countenance assumes a distressed, pale, and sickly aspect; its 
sleep is disturbed by sudden starts; it often cries out suddenly, 
as if in violent pain ; and, in most instances, fatal irritation, and 



32 OF THE NOURISHMENT 

effusion in the brain, finally ensue, and terminate the infant's 
sufferings. 

Besides the foregoing sources of injury to the health and com- 
fort of the infant, there are many others, scarcely less detrimen- 
tal in their tendency, incident to wet-nursing, and which can 
seldom be wholly avoided, when this mode of nursing is adopted. 
To attend properly to an infant, by day and by night, requires 
sacrifices of ease and comfort, on the part of the nurse, which are 
not often fully submitted to by hired nurses. The mother alone 
can experience those instinctive and anxious promptings, to ad- 
minister to the wants and comforts of her offspring, which are 
necessary to secure the faithful performance of this important 
duty. Children often suffer much from the indolence and care- 
lessness of nurses. They are suffered, frequently, to lie, for 
hours, in their wet and soiled diapers, and to remain for days 
without proper ablutions. Much neglect too, is sometimes prac- 
tised in suckling the infant. Its stomach is now engorged with 
milk, that the nurse may have time to walk out, or attend to 
some of her own affairs, and then, all nourishment is withheld for 
an unreasonable length of time. At night particularly, the nurse 
is too indolent or too sleepy to keep the child clean and dry, and 
to apply it regularly to the breast; and in order that it may not 
disturb her rest, laudanum, paregoric, or some other anodyne, is 
clandestinely given to the little victim. The same culpable prac- 
tice of stupifying the infant with laudanum, is often resorted to 
during the day, in order that the nurse may attend to some affair 
of pleasure, or business on her own account. These are not ima- 
ginary charges. I have repeatedly known them practised, where 
such mismanagement was not suspected; and too much vigilance 
cannot be exercised in observing and scrutinizing the conduct of 
nurses. It is to be observed moreover that the child is liable to 
very serious injury from irregular habits on the part of the mo- 
ther. Intemperate nurses are particularly to be reprobated. I 
have, in several instances, known infants to be very seriously in- 
jured by nurses of this description. Women who hire themselves 
out for wet-nurses, appear to be more liable to this vice, than 
almost any other class of females. Under an idea, that while 
suckling, they require some stimulus to support their strength, 
and to promote the secretion of milk, they are apt to drink freely 
of malt liquors, which often leads them, in the end, to resort to 
the more ardent alcoholic liquors. Thus, the habit of intempe- 
rance is sometimes formed; and although they may not drink to 
the extent of producing intoxication, yet the milk will become 
unwholesome and injurious to the infant nourished by it. 

From the foregoing remarks, founded on experience and obser- 
vation, the impropriety of excluding the child from the mother's 



OF INFANTS. 33 

breasts, and submitting it to the nursing of a stranger, is very 
manifest. To be obliged to procure a wet-nurse is always an 
evil, and cannot but be viewed as such, by every sensible, hu- 
mane, and good mother. 

Unfortunately, however, mothers are not always in a condition 
which enables them to suckle their own infants; and the employ- 
ment of a wet-nurse, or recourse to artificial nursing, is unavoida- 
ble. The causes which may prevent the mother from nursing 
her child are: 1, A decided deficiency, or total failure in the se- 
cretion of milk, in consequence of organic disease or functional 
torpor of the breasts. 2, A bad state of milk, rendering it deci- 
dedly prejudicial to the health of the child. 3, The presence 
of a morbid taint, or some communicable chronic disease in the 
maternal system. 4, When suckling gives rise to painful or 
dangerous affections in the mother, as colic, cough, distressing 
nervous affections, great weakness, epilepsy, &c. 

When causes of this kind render it improper or impracticable 
for the mother to nurse her child, it then becomes a question 
whether a wet-nurse should be employed, or artificial nursing 
resorted to. If a healthy, fresh, and faithful nurse can be pro- 
cured, this mode of nourishing the infant, is certainly preferable 
to artificial nursing. It is not often, however, that a nurse can 
be obtained who is, in all respects, well qualified for this office. 
In general, a nurse who has no child of her own to take care of, 
is much to be preferred to one who has this additional charge; 
more especially when the infant intrusted to her care, is removed 
from the immediate observations of its parents. The foster-child 
is always more or less neglected when the nurse has an infant of 
her own to attend to. If there is a deficiency of milk for both, 
the promptings of maternal feeling, will be very apt to favour 
her own child; and, if the latter should become sick, and require 
particular attention, the foster-babe will seldom receive proper 
nursing. When the wet-nurse is received into the parents' house, 
the superintendence of the mother, may, in general, prevent such 
misconduct on the part of the nurse; but when the child is nursed 
out of the house, and removed from the presiding care of a watch- 
ful parent, the probability of its being neglected and maltreated 
is always very considerable. It would, in general, be much bet- 
ter to nurse the child artificially, under the eye of its mother, 
than to place it entirely at the mercy of the wet-nurse. Nurses, 
doubtless, are sometimes found, to whom a child may be safely 
intrusted; but experience has but too often shewn that the 
reverse is much more common. 

Attention must also be paid to the previous and present health 
of the nurse. No woman, who has led a debauched course of 
life, even though reformed, can be regarded as a perfectly safe 
F 



34 OF THE NOURISHMENT. 

nurse, however careful and attentive she might otherwise be. 
Females of this description are apt to have their systems contam- 
inated with some morbid taint, which may give an unwholesome 
quality to the milk, and injure the child's constitution. The ex- 
istence of scabby or scaly eruptions on the skin, unless they are 
of transient character, and of chronic ulcers, particularly on the 
legs, should be regarded as sufficient objections to a nurse. A 
manifest scrofulous habit, also, is decidedly objectionable. The 
age of the milk is another point of considerable importance. 
Milk that is six or seven months old, seldom agrees well with 
infants during the first two or three months after birth. In gen- 
eral the milk becomes much more rich and nutricious after the 
fourth month, than it is previous to this period; and hence milk 
of this kind, from its requiring stronger digestive powers than 
younger milk, often gives rise to much disturbance of the stom- 
ach and bowels in new-born infants. As a general rule, there- 
fore, the age of the milk, should not vary much from that of the 
child, up to about the fourth month. After this period, such a 
relation between the ages of the milk and child is not of much 
importance; for a child five or six months old and upwards, may 
be well and safely nourished by a fresh breast. 

The occurrence of the menstrual evacuation, during lactation 
is almost invariably attended with diminution and deterioration 
of the milk; and constitutes a well-grounded objection to a wet- 
nurse. This is more especially the case during the first three or 
four months of infancy. When a child, at this early period, is 
put to the breast of a nurse who menstruates, it rarely fails to 
experience derangements of the stomach and bowels. After the 
seventh or eighth month of age, there is much less inconvenience 
and disorder to be apprehended from this source; but even at 
this advanced period of infancy, the milk of a nurse, thus circum- 
stanced, may give rise to disturbances in the digestive organs, 
and should, if possible, be avoided. Nature, here, as elsewhere, 
is a safe guide. We perceive that menstruation is almost univer- 
sally suspended during the period of suckling; and we may pre- 
sume that this arrangement of nature is designed for some useful 
purpose — for the well-being, doubtless, of the infant. Nature, 
therefore, as well as experience, indicates the propriety of with- 
holding the breast from the child, when from constitutional 
peculiarity, or some accidental influence, the menses make their 
appearance in the nurse. 

A nurse who has but one good breast should never be selected. 
A child suckled by one breast only, is apt to contract the habit 
of squinting, from having its eyes constantly directed to one side; 
and there is also some risk of its head and shoulders acquiring an 
oblique or crooked form. Even when both breasts are perfect 



OF INFANTS. 35 

and exuberant, some nurses are disposed to suckle principally 
with one only. This should not be permitted. The child should 
be nourished alternately from both breasts. Some attention 
should also be paid to the nurse's nipples. If they are very small, 
the child will be apt to fatigue itself in sucking, without being 
able fully to satisfy its wants. This defect can seldom be pro- 
perly remedied. The practice of drawing out the nipples by 
suction, with a tobacco pipe, will be of advantage; but when the 
nipples are very small, and deeply imbedded in the breast, it can 
scarcely remedy the evil. In some instances the nipples yield 
the milk so freely, that the child is continually harassed by a 
sense of strangulation, while suckling, from inability to swallow 
as rapidly as the milk issues into its mouth. This may, in gene- 
ral, be remedied by passing a piece of fine tape pretty firmly 
round the base of the nipple; or the nurse may compress the 
nipple moderately between the first and second fingers, while the 
child is suckling. 

Finally, particular regard should be had to the temper and 
moral babits of the nurse. An irritable, passionate, and sour- 
tempered female is but illy suited for this important duty. Not 
only is the child liable to be maltreated by a nurse of this char- 
acter, during the fits of ill-nature and passion; but the most seri- 
ous and alarming effects may be produced on its tender organiza- 
tion, by the milk of such a nurse. It is well known that violent 
anger, and habitual sourness of temper are peculiarly apt to give 
a pernicious quality to the milk. Children have been thrown 
into convulsions, by suckling soon after the nurse has been agita- 
ted by violent anger or rage; and alarming vomiting and purging 
is particularly apt to occur from this cause. Indeed every kind 
of inordinate excitement, or depression of the mind is unfavoura- 
ble to the secretion of healthy milk. Protracted grief, sorrow, 
or mental distress and anxiety in the nurse, seldom fail to exert a 
prejudicial influence on the health of the nursling. This circum- 
stance ought not to be overlooked, in choosing a wet-nurse. Wo- 
men, whose domestic relations expose them to moral affections 
of this kind, cannot be regarded as well adapted for this office. 
Tranquility of mind, and evenness of temper are particularly 
desirable in a nurse; and no female ought to be admitted to this 
duty, who is, either by temperament, or extraneous circumstances, 
placed in an opposite condition. 

Artificial Nursing. — Under judicious management, infants will, 
in general, experience no particular inconvenience from a course 
of artificial nursing; and, as a general rule, this mode of nourish- 
ing children, when properly conducted, is upon the whole prefer- 
able perhaps, to the employment of a wet-nurse whose competency 
and fitness is equivocal. This preference, however, is founded 



36 OF THE NOURISHMENT 

rather on the greater risk which the child incurs of being mal- 
treated and neglected, when submitted to the exclusive care of a 
wet-nurse, than when nursed artificially, under the immediate su- 
perintendence of a parent; for there can be no doubt, that fresh 
human milk, when uncontaminated, is always the best possible 
nourishment for infants. 

There are indeed circumstances, in relation to the condition 
of the child, which render the employment of a wet-nurse, not- 
withstanding all the risks that have been mentioned, decidedly 
preferable to artificial nursing. Very young, and peculiarly del- 
icate and feeble infants, seldom do well when raised by the hand. 
Fresh and wholesome milk from the breasts of the mother, or a 
healthy nurse, is almost indispensable to the well-being of an 
infant thus circumstanced. The same observations apply to 
infants, whose stomach and bowels are peculiarly weak and irri- 
table, and consequently particularly liable to disorder, from 
even slight sources of gastro-intestinal irritation. Finally, if upon 
trial, the slightest and most appropriate kinds of artificial aliment 
are found to disorder the alimentary canal, the life of the infant 
will very probably depend, on its being nursed by a fresh and 
wholesome breast. 

In many instances, however, it is wholly impracticable to pro- 
cure a suitable wet-nurse, and artificial nursing becomes unavoid- 
able. Sometimes the mother, though incapable of supplying a 
sufficient quantity of nourishment by the breast, is still able to 
furnish small portions of wholesome milk, and when this is the 
case she ought by all means, to continue suckling the child, in 
conjunction with the use of artificial nourishment. The kind 
of aliment which should be employed, and the mode of feeding 
proper, in cases where there is a deficient secretion of milk in 
the maternal breasts, have been pointed out. A mixture of two 
parts of fresh cow's-milk, and one part of warm water, with a 
very small portion of sugar will, in general, answer the purpose 
better than any other article of food, that can be contrived. 
Thin barley-water, or a very liquid preparation of arrow-root, 
will sometimes be useful as a change of nourishment, where, from 
accidental weakness, or a prevailing acidity in the stomach, the 
milk curdles, and causes griping. As has already been men- 
tioned, the sucking-bottle is decidedly the best mode of feeding 
the child. Particular care should be taken to keep the bottle 
perfectly clean and sweet. It should be well washed, both in- 
side and outside, with hot water, every morning and evening. 
The same food should not be suffered to remain in the bottle more 
than three or four hours. When kept too long it is apt to turn 
sour, and to become injurious to the child's stomach and bowels. 
After the child has satisfied its appetite, no new supply of food 



OF INFANTS. 37 

should be added to what may have been left. The quantity of 
nourishment put into the bottle, should not be much greater than 
what may be deemed fully sufficient for one nursing; and if any 
remains, it should be emptied and the bottle well rinsed with 
fresh water. By these precautions the food will always be sweet, 
and free from offensive or irritating qualities. Dr. Dewees ad- 
vises that " the extremity from which the child is to suck should 
be covered with a heifer's teat, in preference to any thing else." 
Teats of this kind, properly prepared, are not, however, always to 
be procured ; nor do they appear to me preferable to a few folds 
of fine and soft linen drawn over the mouth-piece, with a minute 
orifice, corresponding with the opening of the tube. The teat is 
often too bulky for the child's mouth, and it is very apt to become 
hard and unyielding, unless removed and immersed in water after 
each nursing; in which case it is, on the other hand, liable to be- 
come too flaccid and relaxed. Two or three folds of soft linen 
are readily applied, and may be taken off and washed, or substi- 
tuted by a fresh and clean piece, without any inconvenience. A 
common eight-ounce vial, or a half-pint decanter, furnished with 
a silver tube having a flat and oblong mouth-piece, will, in gen- 
eral, answer this purpose very well. When the child uses the 
bottle, it should be taken up and supported in an easy semi- 
recumbent position, on the lap or arms of the nurse. The prac- 
tice of dandling and jolting infants soon after they have taken 
nourishment, is decidedly improper. The child should be kept 
quiet for at least thirty or forty minutes after having received its 
nourishment. Rest is particularly favorable to digestion: more 
especially during its primary stage. It would seem as if the di- 
gestive organs required a concentration of the vital energies upon 
themselves, to enable them to perform this important function with 
due rapidity and ease. Nature constantly verifies the truth of 
this observation. All animals manifest an inclination for repose 
and quietude after a full repast; and experience has shown that, 
the process of digestion is particularly liable to be impeded by 
strong mental or corporeal exercise or agitation immediately after 
a full meal. 

Children, who are entirely nursed by artificial diet, should be 
restricted to the use of the milk-and-water mixture mentioned 
above, until several teeth have made their appearance. They 
will, in general, enjoy more perfect health and thrive better, when 
nourished exclusively with this simple aliment, than under the 
use of any other nourishment that can be made. After the third 
month, however, the proportion of milk should be somewhat in- 
creased : namely, three parts of milk to one part of water. After 
the first teeth are protruded, the food may be a little more varied 
and substantial. Grated crackers dissolved in warm water; oat- 



38 OF THE NOURISHMENT 

meal gruel; liquid preparations of arrowroot, tapioca, or sago; 
milk thickened with rice flour, and thin pap, may be allowed in 
moderate quantities along with the ordinary milk-and-water mix- 
ture. When these preparations do not agree with the child's 
stomach, they should be mixed with an equal portion of weak 
mutton, chicken, or beef broth, clear and well freed from fat. A 
mixture of this kind is, in general, easily digested, and rarely 
causes any unpleasant effects on the alimentary canal, when used 
after the first teeth have made their appearance. With some 
children, no form in which cow's milk can be given will agree 
with the stomach. In such cases, farinaceous decoctions, mixed 
with a small portion of cream, are generally digested with perfect 
ease. Thin oat-meal gruel, or rice flour boiled in water, with 
the addition of a teaspoonful of cream to each gill of the liquid 
preparation, will answer very well. 

After the first grinding teeth are protruded, weak broths, 
slightly thickened with oat meal, rice flour, arrowroot, or grated 
crackers, mixed with milk, constitute, in general, the most appro- 
priate articles of nourishment. A small portion of stale bread 
may also be allowed, two or three times daily, at this stage of 
infancy; but all solid animal food should be withheld until the 
canine teeth have made their appearance. After these teeth are 
protruded, small portions of animal food, in a solid state, may be 
allowed with perfect propriety. " The animal food given to 
young children should be plainly roasted or boiled. Fried and 
broiled meats, and all food heated a second time, by hashing or 
mincing, being less digestible, should be avoided. Many people, 
from a mistaken expectation of strengthening weakly children, 
give them more animal food, and sometimes twice or thrice a day ; 
but it will be found much more frequently to add to the debility 
than to the increase of strength. Those children, on the whole, 
who eat the least animal food, are the most healthy. Nothing is 
more absurd than the notion that, in early life, children require a 
variety of food. One food only is provided by nature for them; 
and it is too presumptuous to assume that the Creator of the world 
acted in error, and that the ingenuity of man is able to correct it, 
or make any improvement in his works." 

The peculiarly excitable state of the system during dentition, 
and the consequent tendency to febrile irritation, render the free 
use of animal food decidedly objectionable during this stage of 
childhood. Small portions of the more digestible meats may be 
allowed to healthy children, once daily, with little or no risk of 
injury; but they should never be permitted to form the principal 
part of the food. The lean parts of mutton, lamb, tender beef, 
game, and fowl, should be selected. Veal, pork, pig, goose, duck, 
and all kinds of salted meats, being of much more difficult diges- 



OF INFANTS. 39 

tion, can seldom be used without impeding digestion, and finally 
injuring the tone of the stomach. Veal is decidedly the most ob- 
jectionable of all the meats in common use. Fresh fish, boiled, 
and taken in moderate portions, seldom disagrees with the sto- 
machs of children, and may be used, occasionally, with perfect 
propriety. Soft boiled eggs, too, form an appropriate article of 
nourishment for children after the first teeth have come out. 
When fried, or boiled hard, they are altogether unsuitable. 
Strongly seasoned meats, compound dishes, ragouts, hashes, meat 
pies, and pastry are to be wholly rejected. Simplicity and plain- 
ness are all-important requisites in the diet of children. Their 
meals should be made on a few plain and simple articles of food. 
Children who are indulged in the use of a variety of food, and in 
compound dishes, very rarely escape debility and irritation of the 
digestive organs. They soon become pale, dyspeptic, irritable, 
and languid. 

The introduction of fresh food into the stomach before that 
which was previously taken is entirely digested, seldom fails to 
operate injuriously on the alimentary canal. To obviate this 
cause of mischief, an effort should be made, as soon as the child is 
weaned, to establish some regularity in the periods of taking 
nourishment; and sufficient time should be allowed for each meal 
to be completely digested before fresh food is taken. If the meals 
are not sufficiently remote from each other, the digestive organs 
will almost inevitably become weakened, from the constant state 
of action in which they are kept by the continual supply of food. 
As a general rule, from three to four hours may be regarded as a 
suitable interval between the meals. If the child requires nou- 
rishment between the regular meals, small portions of liquid ali- 
ment should be used. When solid animal food forms a part of 
the diet of children, it should be taken at noon, or in the fore- 
noon. It should not be taken more than once daily, as a general 
regulation. 

Pure water, with or without small portions of milk, constitutes 
the best drink for children, as it docs for adults. The practice of 
allowing them a little wine, spirits, or malt liquors, is decidedly 
reprehensible. Children require no stimulus of this kind to excite 
and sustain their vital functions. The use of such drinks is espe- 
cially improper during the irritable period of dentition. There 
exists, naturally, a strong tendency to a preternatural determin- 
ation of blood to the head, in early childhood, — particularly while, 
the process of dentition is going on. Some of the most fatal dis- 
eases of infancy are intimately connected with this condition of 
the circulation; and it is obvious, that the use of alcoholic stimu- 
lants must have a direct tendency to increase this irregular flow 



40 OF THE NOURISHMENT 

of blood to the head, and consequently to increase the liability to 
inflammatory diseases of the brain. 

Sweetmeats. — Indulgence in the use of sweetmeats is a copious 
source of disease and mortality during childhood. Dried fruits 
preserved with sugar, nuts, baked sugar, &x. are among the most 
indigestible substances employed as food. There are few individ- 
uals, even in adult age, whose digestive organs are sufficiently 
vigorous to digest such articles with facility; and their frequent 
or abundant use rarely fails to impair the tone of the stomach, 
and to cause intestinal disturbances. Fruits preserved with their 
skins, as raisins, are particularly pernicious. The cuticle, or skin, 
of all fruits is of peculiarly difficult digestion. The most active 
digestive powers are, in general, insufficient to digest this portion 
of fruits. Added to this the hard and insoluble seeds which rai- 
sins and many other fruits in common use contain, render them 
highly irritating and injurious to the alimentary canal. In vain 
are judicious dietetic regulations adopted for the nourishment of 
children, if articles of this kind are allowed. I have known two 
or three raisins to produce the most serious and protracted disor- 
der of the intestinal canal in infants. Three instances have oc- 
curred to me, in which convulsions and speedy death were, une- 
quivocally, the consequence of overcharging the stomach with 
this indigestible and irritating fruit; and my friend, Dr. Cobb, 
has recently communicated to me a case, which occurred in his 
own family, of the most alarming character, produced by the 
same cause. The infant appeared to be well when put to bed. 
On attending to it about midnight, it was found cold, pulseless, 
with a deathlike expression of the countenance, and apparently 
dying. In a short time spontaneous vomiting came on, by which 
a large quantity of raisins was thrown from the stomach, after 
which all the alarming symptoms speedily disappeared. The 
raisins had been given to the child by a servant of the family 
without the knowledge of its parents. 

The conduct of parents, in relation to this subject, is often ex- 
tremely irrational and pernicious in its consequences. They 
would not themselves venture on the frequent and free use 
of confectionaries of this kind; and yet will indulge their children 
without scarcely any restraint, in the use of these pernicious luxu- 
ries. The sicklier and weaker the child is, the more apt, in gen- 
eral, is it to be allowed these destructive gratifications. The 
pale, feeble, and sickly child, whose stomach is hardly able to di- 
gest the most simple and appropriate aliment, is sought to be ap- 
peased and delighted by the luscious and scarcely digestible arti- 
cles of the confectioner. Indigestion, intestinal irritation, termin- 
ating often in ulceration and incurable diarrhoea, are the frequent 
consequences of such conduct; and at best, such indulgences must, 



OF INFANTS. 41 

inevitably, prolong the feeble and sickly condition of the child, 
and not unfrequently eventuate in permanent constitutional 
infirmity. 

With regard to the use of fresh fruits, writers, on this subject, 
have expressed different opinions. Apples, peaches, and apricots, 
when perfectly ripe and mellow, may be occasionally allowed to 
children, in moderate portions, with entire safety, unless the sto- 
mach and bowels be very weak and irritable. In children of a 
costive habit, the temperate use of these fruits may even have a 
beneficial effect, by their tendency to excite the action of the 
bowels. Nothing, however, of this kind is more prejudicial to 
health than unripe fruits. Unripe apples, so frequently seen in 
the hands of children, are particularly injurious; both on account 
of the difficulty with which they are digested, and the peculiar 
and pernicious quality of the crude juice, or acid, which they 
contain.. Pears, even of the tenderest kinds, appear to be much 
more indigestible than ripe apples or peaches, and seldom fail, 
when freely taken, to cause some uneasiness and disturbance in 
the alimentary canal. Stewed or roasted fruits, particularly the 
two latter kinds, are, in general, well adapted to the digestive 
powers of young children, and maybe allowed, occasionally, with 
perfect propriety, provided they are not very sour. When the 
acid prevails to such a degree as to require the addition of sugar 
to render them sufficiently palatable, stewed or roasted fruits of 
this kind rarely agree well with weak and delicate stomachs, and 
cannot be allowed to young children without considerable risk of 
unpleasant consequences. 

In general, all fruits having a firm cuticle or skin, such as 
grapes, whortleberries^ &c. are improper articles of food for 
children. The latter berries, especially, are invested with so 
firm a cuticle, that even the most energetic digestive powers are 
insufficient to dissolve it; and it is, doubtless, in part, on this 
account, that of all fruits of the kind they are the most apt to ex- 
cite internal irritation and diarrhoea. The pulp of grapes, freed 
from the seeds, rarely causes disorder in the alimentary canal, 
when taken in moderation; and children may be safely indulged 
in the use of small portions of it. When swallowed with the skin 
and seeds, however, grapes are decidedly hurtful; and, as chil- 
dren rarely attend properly to the rejection of these parts, this 
fruit cannot be put into their hands, without considerable risk of 
injury from this source. Fruit, that contains small, hard and in- 
soluble seeds — such as strawberries, blackberries, currants, &c. 
are particularly apt,. when freely taken, to disorder the alimentary 
canal. The seeds, resisting the digestive powers, irritate the mu- 
cous membrane of the bowels; and when, from previous causes, 
this membrane has become enfeebled and irritable, they may 

G 



42 OF THE NOURISHMENT OF INFANTS. 

readily excite dangerous irritation. Small insoluble bodies of 
this kind, frequently remain lodged in the folds of the bowels for 
many days and even weeks, and give rise to severe and unmanage- 
able disorders of the alimentary canal. I have known a child to 
evacuate from its bowels a great many small seeds, three weeks 
after the fruit which contained them had been eaten; and during 
all this time it had suffered painful and exhausting diarrhoea. 
Cherries are among the most pernicious fruits in common use, and 
ought to be wholly excluded from the list of articles with which 
children may be occasionally indulged. Even when eat without 
the stones, they are peculiarly apt to derange the bowels; and when 
swallowed with the stones, which, with children, is not unfre- 
quently the case, they are capable of producing violent and even 
fatal impressions on the alimentary tube. No small number of 
instances have come under my notice, where the most alarming 
and, in a few cases, fatal consequences resulted from the irrita- 
tion of cherry stones lodged in the bowels. Convulsions, inflam- 
mation, unconquerable constipation, and exhausting and harrass- 
ing diarrhoea, are among the affections which are apt to arise 
from this cause. All fresh fruits have a tendency to excite, more 
or less strongly, the peristaltic action of the bowels. As a gene- 
ral rule, therefore, every kind of fresh fruit is improper for chil- 
dren whose digestive organs are weak and irritable, or who are 
habitually liable to disorder of the bowels. If the digestive pow- 
ers are vigorous, and there exists no obvious tendency to bowel 
complaints, small portions of the fruits in common use, the seeds 
and skins being rejected, may be allowed occasionally, with 
little or no risk of mischief. It is of much importance, however, 
that the quantity of such articles taken into the stomach at a time 
be moderate ; and that they should never, with children, be suf- 
fered to form the whole, or even principal part, of meals. 






OF EXERCISE. 43 



CHAPTER III. 

OF EXERCISE. 

The importance of permitting the infant to have the unre- 
strained use of its limbs, has already been dwelled on, when 
speaking of Dress. At first, its spontaneous motions are, indeed, 
but very limited ; for the muscular power, and the command of 
volition over it, are acquired in a very gradual manner. Uncer- 
tain and awkward motions of the arms — stamping with the legs, 
and drawing them up, are the first feeble attempts which the in- 
fant makes in the use of its muscles. But even these muscular 
exertions appear to be indispensable to the preservation of its 
health and the proper developement of its powers; and it should 
be an especial object of care to allow entire freedom of motion, 
several hours daily, by avoiding all modes of dress and position 
tending to restrain the free use of the extremities. With this 
view, the infant should be taken from its bed and laid on its back 
upon a soft mattress, or any other level and slightly resisting sur- 
face, and divested of every thing calculated to restrain the mo- 
tion of its limbs and body. When thus indulged with freedom of 
action, it will soon exercise its feeble limbs, by moving them in 
various directions; and manifest, " by its repeated and apparently 
earnest, efforts, how much it enjoys this exemption from restraint." 
This should be repeated two or three times daily; and in warm 
weather the air should be freely admitted. Voluntary exertions 
of this kind are much more efficient in developing the powers of 
the muscular system, and bringing it early under the commands 
of volition, than any of the passive modes of exercise in common 
use. Children, who are frequently permitted to exercise their 
muscles in this way, will, cateris paribus, learn to use their limbs 
and walk earlier and more steadily than those who are seldom 
allowed this freedom of voluntary action. 

Carrying. — Besides the exercise which infants thus obtain by 
their own muscular efforts, passive exercise should be regularly 
afforded them, by carrying in the arms and riding in an easy car- 
riage. This kind of motion, when conducted in a proper way, 
has a highly salutary influence on the developement and vigor of 
the infantile organization. The use of it should be commenced 



44 OF EXERCISE. 

as early as the second or third day after birth, provided the infant 
be not unusually feeble; and it should be daily attended to, as 
one of the regular and indispensable duties of nursing. The man- 
ner, however, in which very young children are usually carried 
or exercised, is extremely reprehensible, as it is calculated to give 
rise to very unfortunate consequences in relation to the health 
and regular conformation of the child's body. I allude, particu- 
larly, to the common practice of carrying infants with their bodies 
in an erect position, before the spine and muscles have acquired 
a sufficient degree of firmness and activity, to support the trunk 
and head in this posture. The child is usually carried by the 
nurse pressing its thighs and hips, with the left forearm, against 
her body, whilst its trunk is balanced in an upright posture, by 
resting lightly against her bosom. Thus the whole weight of the 
infant's trunk rests upon the feeble and yielding spine, while the 
unsupported head is, in general, suffered to lean constantly to 
one side, or to roll about in every direction. It requires but little 
reflection to perceive, that this mode of carrying infants must in- 
terfere, very materially, with the regular and symmetrical devel- 
opement of the body. The feeble spine, yielding to the super- 
incumbent weight of the head and body, is always curved out- 
wards while the infant is held or carried in the erect position; 
and, when this is daily repeated, for several hours, as is frequent- 
ly the case, the back is liable to become permanently bent or 
distorted. A habit, too, of leaning the head to one side is some- 
times contracted by the child; and, from the violent manner in 
which the head is liable to fall from side to side, serious and even 
fatal injury may be inflicted on the spinal marrow of the neck — 
a remarkable instance of which is related in Hufeland's Journal. 
But even after the spine and its muscles have acquired a sufficient 
degree of firmness, to enable the child to support its head and 
body in the erect position, without difficulty, it incurs considera- 
ble risk of injury from the usual practice of carrying it, almost 
exclusively on one arm. Nursery-maids are very apt to fall into 
this error, unless particularly directed to change the arm on which 
the child is carried. When this precaution is not used, and the 
child is carried almost wholly on one side, it is apt to acquire 
the habit of leaning to one side, which it is always very difficult 
to correct. The child, also, when carried in this manner, usually 
throws one of its arms around the neck of the nurse, in order to 
support itself more steadily in the erect position; and of course 
always with the same arm, when the side on which it is carried 
is not changed by the nurse. In consequence of this position, the 
shoulder-blade and side of the chest are liable to be forced up- 
wards and outwards, which may ultimately result in permanent 
distortion of these parts. The manner of carrying infants is, in- 



OF EXERCISE. 45 

deed, of far greater moment than seems to be generally supposed. 
Many a parent has had occasion to lament the unfortunate con- 
sequences which may result from the errors just mentioned; and 
yet, it must be confessed, that mothers seldom pay that attention 
to this subject which reflection and maternal solicitude would 
seem to suggest. 

The spine and its muscles seldom acquire sufficient strength 
and firmness, before the end of the third month, to enable the 
child to support its body in an upright position, without inconve- 
nience or risk of injury. Until this power is manifestly acquired, 
the infant should not be carried, or suffered to sit, with its body 
erect, without supporting it in such a manner, as to lighten the 
pressure made on the spine, and aid it in maintaining the upright 
posture of its head and trunk. But even when thus supported 
by the nurse, it should not be kept in an erect position more than 
one or two minutes at a time, and not until it is four or five weeks 
old. At first (a few days after birth) the infant should be taken 
from its cradle or bed, two or three times daily, and laid, on its 
back, upon a pillow, and carried gently about the chamber. 
Struve observes that, the best mode of carrying very young in- 
fants is, to lay them into a small oblong basket. By this contri- 
vance a gentle and agreeable swinging or undulating motion will 
be communicated to them; and the sides of the basket being 
three or four inches higher than the child's body, a cover may be 
thrown over it, without restraining the free motion of its limbs. 
After the third or fourth week, the rhild may be carried in a re- 
clining posture on the arm of a careful nurse, in such a way as 
to afford entire support to the body and head. This may be done 
by reclining the infant upon the forearm, the hand embracing 
the upper and posterior part of the thighs, whilst its body and 
head are supported by resting against the breast and arm of the 
nurse. When held in this way, it may be gently moved from 
side to side, or up and down, while it is carefully carried through 
a well ventillated room. When it is found that the child has 
acquired a sufficient degree of muscular power to maintain itself 
in a sitting posture — which rarely occurs before the completion 
of the third month — it may be carried about, in this position, for 
a short time, twice or thrice daily, provided the spine and head 
be supported by the nurse : an aid which can seldom be pru- 
dently dispensed with before the child is six or seven months old. 
"During the first six months," says Struve, " the head of the infant 
should, in carrying, be supported by the nurse's hand ; for the 
muscles of the neck are, at this tender age, too delicate to pre- 
serve the head in an erect posture." Mothers are fond of exhib- 
iting the exploits of their babes, in raising and supporting their 
heads — " unconscious of the mischief which may be occasioned 



46 OF EXERCISE. 

by this premature experiment." It is painful to see the violent and 
generally abortive efforts, which the infant makes to steady its 
head, when raised into a sitting posture. It will sometimes suc- 
ceed in balancing its head for a moment, to the great delight of 
the fond mother; but the effort is almost invariably speedily fol- 
lowed by a sudden and often violent rolling of the head from side 
to side, which cannot but have an injurious tendency. 

All rapid, whirling, and concussive motions are calculated to 
injure the health and delicate organization of infants; and moth- 
ers should be particularly vigilant in preventing nursery-maids 
from subjecting their charge to such violence. Running or jump- 
ing with an infant in the arms — descending rapidly a flight of 
stairs — whirling round, &c. ought to be rigidly forbidden, as they 
are attended with much risk of some serious accident, and may 
interfere with the regular distribution of the circulation, and the 
healthy action of the brain and other important organs. The 
practice of supporting very young infants in a sitting posture on 
the knee, and jolting them violently, cannot be too severely cen- 
sured. It is not uncommon to see mothers and nurses jolt infants 
in this manner, with a violence that threatens dislocation, and 
manifestly occasions them much pain and distress. Tossing them 
rudely on the arms, though less concussive than jolting on the 
knee, is equally reprehensible, as it is attended with more risk of 
injury from falls, blows, &c. These violent agitations, "power- 
fully affect the delicate organization of infants, and may be pro- 
ductive of spasms, epilepsy, and appoplectic fits." Gentle and 
cautious tossing on the arms, affords an agreeable exercise of the 
body, and may be salutary by the moderate agitation which it 
causes in the internal organs. 

Different opinions have been expressed with regard to the pro- 
priety of rocking infants in cradles. To gentle and cautious 
rocking, there can be no just objection. The swinging, or rolling 
motion of the cradle, communicates an agreeable sensation to the 
system, and disposes to calmness and repose: and when mode- 
rately practised, and not very often and long continued, it can 
scarcely give rise to any evil consequences. It is otherwise, how- 
ever, with violent, rude, and almost constant rocking. Rapid 
and long-continued rocking motion, instead of merely calming the 
excitement of the brain and inducing a state of agreeable repose, 
as is the case when gently and slowly performed, is apt to disor- 
der the actions of this organ, in a very decided manner, and, 
through it, to exert an injurious influence on the whole organiza- 
tion. With infants predisposed to diseases of the head, strong 
rocking should be particularly avoided. 

Riding in a Carriage. — This is an excellent mode of affording 
suitable exercise to infants, and may, with great propriety, be 



OF EXERCISE. 47 

employed as an occasional substitute for carrying in the arms. 
When cautiously managed, it affords a gentle, uniform, and very 
agreeable motion, for which children, in general, soon contract a 
great fondness. 

The body of the carriage should be long enough to permit the 
infant to lie down at full length; and the sides ought to be suffi- 
ciently high to prevent it falling or rolling out. The wheels 
should be low, in order to lessen the liability of oversetting; and 
they must be carefully secured " against running off when the 
carriage is in motion." Like carrying in the arms, this mode of 
exercising infants is liable to be conducted in a very improper 
and hazardous manner. This duty is usually entrusted to children 
or young girls, who being generally more disposed to consult their 
own sportive inclinations than the comfort and safety of their 
charge, are apt to draw the carriage along with great rapidity, 
paying little or no attention to the roughness or unevenness of the 
ground over which they pass. Such careless conduct ought to 
be particularly forbidden by parents; and especial instructions 
given, that the carriage be drawn along with a moderate and 
steady pace, and over level grounds. Very young infants should 
be laid down in the carriage, on a pillow or a small and soft mat- 
tress, with the head slightly elevated, " and so confined at the 
sides as to prevent them from rolling when in motion.''' After the 
child has acquired some degree of strength, it should be placed in 
a semi-recumbent posture, with its head and back well supported 
by pillows, &c; and when it is capable of supporting its head, it 
may be permitted to sit upright in the carriage, being properly 
secured against being thrown from side to side by the rolling of 
the carriage. * 

Walking. — After the infant has acquired sufficient strength to 
support itself in the sitting posture, it should be placed on a soft 
carpet, several times daily, and surrounded with its toys. When 
thus left to the free use of its limbs, it will soon learn to crawl — 
an exercise which should always be freely allowed, and even en- 
couraged, as the most natural preliminary muscular effort to the 
more difficult one of walking. The common practice of teaching 
children to walk, by supporting them, prematurely, on their legs, 
and leading them forward, without allowing them the advantage 
of having their muscles previously strengthened and in some de- 
gree brought under the commands of the will, by the initial loco- 
motive exercise of crawling, is objectionable on various accounts. 
It seldom fails to produce more or less unnatural curvature of the 
legs; and in infants of a scrofulous or ricketty habit, it may 
readily give rise to distortion of the spine and round shoulder. 
Children, who are permitted to exercise their muscles by crawling, 
generally acquire a much firmer step, and enjoy more robust 



48 OF EXERCISE. 

health, than « those who have been taught to walk without this 
useful intermediate muscular discipline." 

" Before infants attempt to walk," says Dr. Struve, " they 
should first learn to crawl. With this intention, they should be 
placed on a large carpet, where they will soon busily employ 
themselves; move and extend their limbs, or roll about to reach 
their playthings. If the weather is serene, and the ground per- 
fectly dry, they may be carried out, and placed on a grassplat, 
where they can range about in all directions; and if they happen 
to fall, they will not receive material injury on the soft ground, 
but rather learn to be more cautious in future. While in the 
nursery, they may be taught to rise from the floor by laying hold 
of chairs; and, if occasionally supported under the arms, they will 
easily learn to stand erect; but they should never be raised up 
by one arm only. At an early age they may be held under both 
arms; and when thus supported, the hands of the attendant be 
occasionally withdrawn for a moment, they will soon acquire the 
power of standing alone. Mild and persuasive language ought 
to be used in these experiments; while the infant may be en- 
couraged by some toys placed at a little distance, which will in- 
duce it to stretch out its little arms, and endeavor to advance to- 
wards the place containing the desirable objects. By such means 
it may be allured to visit different parts of the room. The first 
journey of this description ought to be attempted only from one 
chair to another; and afterwards, the little traveller may run to- 
wards its mother, or nurse, who stoops to receive it with extended 
arms. As the child improves in its efforts to walk alone, the 
chairs may be placed at a greater distance from each other; and 
when it sees its older companions run and jump about, it can 
scarcely be restrained, so anxious is it to be placed on the floor, 
that it may crawl or waddle after them. At length, parents are 
gratified with one of the most delightful scenes : they behold their 
child for the first time walking without any assistance. If we are 
earnestly desirous of training up our children in such a manner, 
that they may acquire a firm step, and well-formed limbs, we 
shall gain our purpose much more certainly and safely, by pursu- 
ing this gradual and cautious mode of teaching them the use of 
their legs, than by the more common practice of placing them, 
prematurely, on their feet, without permitting them the previous 
exercise of crawling." 

Leading-strings and go-carts, formerly so much in use, are now, 
very properly, almost universally abandoned. The former con- 
trivance is calculated to do very serious injury, by the rude man- 
ner in which infants are liable to be pulled about by inconside- 
rate or illnatured nurses; for, when the child makes "a false step, 
or inclines too much forward or to one side, and is in danger of 



OF EXERCISE. 49 

falling, it is usually raised by a sudden and violent pull at one or 
both strings. Dislocations and other painful injuries have fre- 
quently been occasioned in this way. Leading-strings, moreover, 
tend to compress and distort the shoulders; and children are apt 
to acquire an unsteady and awkward gait, when taught to walk 
in this manner. Go-carts are still more objectionable. They 
confine and constrain the body in a very uncomfortable manner; 
and, as in pushing the machine along the floor, the breast is usu- 
ally firmly pressed against the circular top, injury may be done to 
the regular developement and conformation of the upper part of 
the chest. The very common practice of teaching infants to 
walk, by holding them by one of their hands, deserves the most 
decided reprehension. When led in this way, the child's arm is 
continually, and often forcibly, extended upwards: if it happen 
to lose its balance, or trip, or if its legs are yet too feeble to sup- 
port itself long, in the erect posture, the whole weight of its body 
is often suspended by one arm. Frequently, too, it is entirely 
raised from the ground by one arm, in order to help it over some 
obstacle, or to hasten its progress over a rough and difficult piece 
of ground. It is easy to perceive that this practice must, neces- 
sarily, and in no inconsiderable degree, tend to draw the shoulder 
and side of the chest out of their natural position; and, when fre- 
quently repeated, to give permanent deformity to these parts. 
From the sudden and violent extension which the arm usually re- 
ceives when the child stumbles, the shoulder and elbow joints 
are liable to be dislocated or sprained, or the clavicle may be 
torn from its attachment with the scapula. I have met with sev- 
eral instances of dislocation of the shoulder joint, which were 
occasioned in this manner; and the occurrence of painful sprains 
— often of several weeks continuance, from violence done in this 
way, is by no means uncommon. Parents should most earnestly 
forbid this mode of leading infants, when entrusted to the care of 
servants out of doors. Nursery-maids seldom exercise sufficient 
care in this respect. Too indolent to carry the infant in their 
arms, as they are directed and supposed to do, they are apt, as 
soon as they are no longer observed, to place the child on the 
ground, and to hurry, or rather, drag it along, in the most care- 
less and unfeeling manner. Of a similar, but still more repre- 
hensible character, is the practice of raising infants from the 
ground by both arms and swinging them about in the air. Frac- 
tures, dislocations, sprains, and other dangerous and painful inju- 
ries, have frequently resulted from this irrational conduct. No 
prudent parent will knowingly permit such an outrage; but, as 
the ordinary attendants on children are often thoughtless and rash, 
they should always be especially cautioned on this point. 

After children have acquired the entire use of their legs, walk- 

H 



50 OF EXERCISE. 

ing is decidedly the best exercise they can take. When the 
weather is fine, they should be taken out daily, and freely in- 
dulged in running and walking about, under the superintendence 
of a careful nurse. These little excursions, if prudently conduct- 
ed, have a highly salutary influence on the infantile system. Chil- 
dren, who are raised in the country, are in general much more 
robust, healthy and active, than those who are brought up in 
cities: and this difference is mainly to be ascribed to the greater 
freedom which the former usually enjoy, of walking, running, and 
tumbling about on grassplats — enjoyments often in a great mea- 
sure denied to the latter. In taking this kind of exercise, children 
should not be accustomed to rely too much on the assistance of 
others. If the ground is favorable; that is, if it is soft or covered 
with grass, and free from stones, timber, &c, they should be per- 
mitted to have their way. A few falls will do them no injury; 
but, on the contrary, make them less timid, and teach them better 
than any other instruction how to avoid a similar accident in 
future. Children, who are never suffered to surmount the little 
difficulties which may occur in their sports, by their own efforts, 
and continually warned against trifling accidents, seldom fail to 
become unduly timid, helpless and irresolute in their actions. 
Parents ought not to intimidate their children, by inspiring them 
with a constant dread of falling or hurting themselves. The cus- 
tom of exaggerating the dangers incident to their usual sports — 
and of plying them continually with admonitory injunctions 
against accidents, when they are engaged in their amusements, is 
calculated to favor the occurrence of the very accidents which 
they are meant to obviate, by the timidity which these perpetual 
lessons of caution and fear almost inevitably inspire. When the 
ground is soft, it is much better to let the child take the chance 
of two or three falls, and give it full scope for the exercise of its 
limbs, by running and gamboling about until it is satisfied. Noth- 
ing can be more invigorating to the whole organization than this 
kind of unrestrained exercise, in suitable situations, and under 
the superintendence of a prudent nurse. Struve, whose excellent 
observations on this subject I have already drawn on so fre- 
quently, observes that, when children happen to fall or hurt 
themselves, they should not be soothed by expressions of extreme 
pity and sorrow ; for plaintive words and expressions of great sor- 
row tend very effectually to render them effeminate and timid. 
Children, who are thus accustomed to excessive commisseration, 
seldom fail to acknowledge this tender sympathy, by straining 
their little lungs to the utmost by crying, on every slight injury 
they receive. 

After children have passed through the period of primary den- 
tition, they should be encouraged in the pursuit of active amuse- 



OF EXERCISE. 51 

ment out of doors, as an essential and regular part of physical 
discipline. Nothing contributes more effectually to enfeeble the 
body, and to lay the foundation of permanent constitutional infir- 
mity, than confinement within doors and want of active exercise 
at this tender period of life. The developement of the moral and 
physical energies of children can in no way be more effectually 
promoted, than by permitting them to engage freely in the usual 
sports of childhood, in the fresh and open air. The practice of 
obliging children to remain within doors, and to con over their 
lessons, between school hours, is by no means commendable. 
These intervals should be devoted to innocent amusement and 
bodily exercise. Trundling the hoop — flying kites— playing at 
ball, shinny, or simply skipping and running about, with other 
juvenile sports unattended with danger, have a decided tendency 
to improve the health and vigor of the system, and should be 
freely permitted during the hours not necessarily devoted to the 
school. Girls may amuse themselves with skipping the rope, 
dancing, walking, shuttlecock, a well constructed and safe swing, 
riding in a carriage, &c. 



CHAPTER IV. 

AIR,— TEMPERATURE,— EXPOSURE. 



That pure air is indispensable to the entire well-being of the 
human organization, is so well established by the common sense 
and experience of mankind, that it seems unnecessary to enforce 
its truth by any especial illustrations. The importance, however, 
of attending particularly to this point, in the management of 
children, does not, in many instances, appear to be sufficiently 
estimated. At no period of life are the effects of confinement in 
stagnant and impure air, more obviously and lastingly detrimen- 
tal to the animal economy than during the feeble and susceptible 
age of childhood. How deeply pernicious a foul and confined 
air is, in its influence on the human system, is most strikingly 
illustrated in the pale, feeble, and sickly aspect of those unfortu- 
nate children who are early placed in manufacturing establish- 
ments, where they are confined, nearly the whole day, in crowd- 
ed and ill-ventilated apartments. Children brought up in the 
crowded and filthy parts of large cities, seldom exhibit a per- 
fectly healthy and vigorous appearance. Go into the country, 



52 OF AIR, &c. 

and you will everywhere meet with children rioting in the exu- 
berance of health— plump, ruddy, robust and active. Exercise 
and simplicity of wholesome diet, doubtless contribute essentially 
to this healthful condition; but, no regulations of diet — no atten- 
tions to exercise, and no sanitary observances whatever, are ade- 
quate to produce a similar fortunate result, when counteracted 
by the continued depressing influence of a confined and contam- 
inated atmosphere. 

Infants ought to be early accustomed to the fresh and open air. 
The practice of confining them, during the first five or six weeks, 
to the close and heated air of nurseries, has a direct tendency to 
impair the energies of the system, and to impede its healthful de- 
velopement. The daily enjoyment of fresh air, for an hour or 
two, contributes very essentially to the health and sprightliness 
of infants; and constitutes one of the most efficient preservatives 
against that delicate and sickly condition, which is so frequently 
witnessed in those who are almost constantly confined and pam- 
pered in nurseries. " Pale countenances, weak eyes, general 
relaxation of the body, an accumulation of all the inconveniences 
and sufferings of childhood — at length consumption and early 
dissolution of life: all these are the natural and frequent conse- 
quences of such confinement. On the contrary, there is no me- 
thod, by which children may be more effectually preserved against 
such unfortunate events, than by permitting them to inhale a 
fresh and uncontaminated air. Pure air is, indeed, most grateful 
to the feelings of children. After having been carried out, but a 
few times, they evince, even at a very early age, a strong desire 
to return to the open air. While yet on the arms of the nurse, 
they anxiously point to the door, and make efforts to approach 
and open it. When they can scarcely crawl, they instinctively 
advance towards that part of the room from which they have a 
prospect of escaping. Hence, in the bosom of nature they expe- 
rience the greatest comfort; and their tears can frequently be 
stopped in no other way, than by taking them out of doors into 
the free air." (Strave.) 

When the weather is clear and of a mild temperature, infants 
should be carried into the open air, once or twice daily, as soon 
as they are two weeks old. During cold and humid weather, 
they should be occasionally conveyed out of the nursery into an 
adjoining well-aired room: avoiding, however, strong currents of 
air, and sitting with them near an open window. Important as 
the enjoyment of fresh air is to the health and comfort of infants, 
care should be taken to accustom them gradually to the impres- 
sions of the external air — more especially when the atmosphere 
is cold and damp. The practice of exposing children, soon after 
birth, at once to the open and cold air, with the view of "hard- 



OF AIR, &c. 53 

ening them," as it is called, is attended with considerable risk of 
injury, and should not be permitted by parents, except when the 
weather is clear and very mild. Catarrhal and other inflamma- 
tory affections are frequently contracted in this way; and in fee- 
ble children, low temperature, when thus suddenly applied, is 
apt to occasion serious depression of the vital energies, and to 
predispose very strongly to the occurrence of febrile and other 
dangerous maladies from the subsequent influence of the ordinary 
exciting causes of disease. Instead^ therefore, of exposing any 
young infants, at once, to the direct impressions of the external 
air, when the state of the atmosphere is unfavorable, they ought 
to be gradually inured to such a transition, by carrying them fre- 
quently out of the nursery into the cooler and less confined air of 
well-aired and unoccupied rooms. In this way, they will soon 
become, in some degree, habituated to sudden transitions of tem- 
perature, and to the more direct impressions of the open air. 
Even in summer, the infant should not, as a general rule, be car- 
ried, at once, into the external air, without having been previ- 
ously accustomed to the air of a well-ventilated chamber. After 
the child is three or four days old, it ought to be conveyed, sev- 
eral times daily, out of its nursery, into a room having, at first, 
only the windows open, and in four or five days afterwards, the 
doors also, so as to admit of a free circulation of the air through 
every part of the room. This having been practised for ten or 
twelve days, the child may then be carried out of doors, and per- 
mitted to enjoy the pure and open air. At first, it should not be 
allowed to remain out of doors more than ten or twelve minutes 
at a time; but the duration of this indulgence must be gradually 
extended, so as to keep it in correspondence with the progressive 
developement of the child's organization and energies. After a 
child has acquired the power of walking, it should be suffered to 
spend a great portion of its time in the open air, and in the pur- 
suit of its ordinary amusements, provided the weather is suffi- 
ciently temperate and dry. Nothing affords more real enjoyment 
to children, and at the same time tends more decidedly to give 
them a sound and active tone of mind and body, than a liberal 
indulgence in exercise and their innocent sports out of doors. A 
country residence possesses many important advantages in this 
respect, which cannot be had in large cities. There, they con- 
stantly breathe a delightful and perfectly pure air, and may be 
safely permitted to run, skip, and tumble about under the shade 
of trees, and on the soft and green surface of a lawn or grassplat, 
almost without restraint and risk of receiving any serious hurt or 
injury. In cities, on the contrary, the atmosphere is always more 
or less contaminated with impure and noxious exhalations; and 
children cannot be prudently permitted to enjoy the same freedom 



54 OF AIR, &c. 

of exercise and active amusement out of doors, as in the country, 
from the constant risk of receiving some injury when suffered to 
be on the side-walk, and the confined and narrow space of ground 
usually allotted to the houses. But, although the atmosphere of 
cities is always far from being perfectly pure, still, the daily enjoy- 
ment of the open air, impure as it may be, is decidedly beneficial, 
and should never be withheld, under an idea, that by free ventila- 
tion and cleanliness the air breathed within may be rendered as 
pure as it is out of doors. In cities of small extent, children "may 
be taken to a garden or field near the town ;" and the larger cities 
generally afford public squares, or parks, devoted to the exercise 
and recreation of the citizens, to which children may be, conve- 
niently, taken, where they may enjoy a free and fresh air, and 
amuse themselves by playing and running about on the grass." 
(Struve.) These little excursions have a very salutary tendency; 
for, besides the excellent effects of the exercise which they afford, 
there is something peculiarly enlivening and grateful in the influ- 
ence of the open air, which children seldom fail to manifest by 
their expressions and actions. When they have the advantage of 
a lawn or grassplat, children should be allowed to amuse them- 
selves freely in their own way. "Boys may be permitted to run 
about, without their hats, though exposed to the wind and sun. 
If they do not, spontaneously, complain of heat or cold, it may be 
considered as a proof that they are in good health; for diseased 
and debilitated children will speedily return to the nursery. If 
they cry, and cannot bear the blast of a moderate wind, or a 
slight degree of cold, it is then proper to return with them to the 
house, as they are probably indisposed; but if, on the contrary, 
we find them lively and cheerful, they may be allowed to con- 
tinue in the air as long as they are comfortable and easy. Chil- 
dren should not be forced against their inclination to go out of 
doors, during a fall of snow or the intense heat of summer. If 
they are once inured to a rough atmosphere, no compulsion will 
be necessary." During the first two or three years of infancy, no 
difference need be observed in relation to this subject between 
boys and girls. Parents are, in general, averse to allowing girls 
the same freedom of exercise and amusement in the open air that 
is usually granted to boys, on account of the tendency which free 
exposure to the atmosphere and the direct rays of the sun has to 
render the skin dark and harsh. A white and smooth skin, and 
a delicate organization are, by many, regarded as marks of a 
genteel education; and these vain distinctions are often sought 
and obtained at the expense of health and a firm constitution, by 
too much seclusion from the external air and light of the sun. 
Girls, like boys, ought to be freely and frequently exposed to the 
open air and weather. The complexion may not become so del- 



OF AIR, &c. 55 

icate and fair, when this freedom of exposure is permitted; but 
the more pleasing appearance of florid and robust health, accom- 
panied with a delightful feeling of buoyancy and vigor, will be 
obtained in its stead : a result infinitely more valuable than fair- 
ness and smoothness of skin and delicacy of structure, — and which 
will extend its salutary influence throughout the whole subse- 
quent period of life. " Not a day," says Willich, " should be suf- 
fered to pass without affording children — both boys and girls — 
the benefit of exercise in the open air. In this instance, custom 
ought to become second nature; they must be inured to external 
impressions; and the daily enjoyment of this balm of life should 
constitute an essential part of their regimen." 

Although children should be permitted to indulge freely in ex- 
ercise and active amusement, during their daily excursions in the 
open air, constant care ought to be had, that they do not lie down 
or sit on the cool and damp ground, or in a strong current of air 
in the shade, when they are in a state of perspiration from exer- 
cise ; nor should they, on any account, be permitted to drink cold 
water, except in very small portions, and at considerable inter- 
vals, when in this heated condition. A neglect of these precau- 
tions is apt to give rise to the most serious consequences. Inflam- 
mation of the brain, lungs, stomach, bowels, liver — catarrhal affec- 
tions, terminating ultimately in disorganization of the lungs, 
croup, and violent inflammatory rheumatism, are often suddenly 
excited by cold and dampness when applied while the body is 
thus especially predisposed to their morbific influence. Nurses 
and servants should always be especially instructed on this point; 
and as soon as children are old enough to comprehend the lessons 
of caution, they should be earnestly impressed with the evil con- 
sequences of these practices, and of the necessity of avoiding them 
as an irremissible condition of their being permitted to run about 
and play out of doors. 

It is not enough, however, that children be taken into the open 
air, for an hour or two daily, in order to secure them the full amount 
of benefit which may be derived from this source ; for unless proper 
attention be constantly paid to the preservation of a compara- 
tively pure and fresh air, in the rooms in which they sleep and 
spend the greater part of their time, the temporary enjoyment of 
the external air cannot effect a great deal towards the permanent 
invigoration and health of their systems. 

Particular care should, therefore, be taken to prevent the air 
of nurseries from becoming impure and stagnant, by proper at- 
tentions to cleanliness and ventilation, and the avoidance of every 
thing which may tend to give rise to unwholesome effluvia. 
When the atmosphere is mild, the external air ought to be freely 
admitted into the room, by keeping a window open during the 



56 OF AIR, &c 

day; and at night the chamber door may be left open, or a sash 
raised, whilst the current of air is intercepted by the closed 
shutters. In cold and humid weather, the upper sash of a win- 
dow should be occasionally drawn down a few inches during the 
day. At night, a window in the adjoining apartment ought to 
be left open, the fresh air being suffered to enter the nursery, by 
the door of communication. Chimney boards, as they impede 
the free circulation of the air in rooms, are decidedly inadmissi- 
ble in well-regulated nurseries. The same objection exists to 
"double doors, linings, listings and sand-bags" — all of which, by 
preventing some degree of ventilation, contribute to an unwhole- 
some condition of the air. Indeed the maintenance of a proper 
circulation of air in the apartments appropriated to children, can- 
not be too strongly urged on the attention of parents. Even 
where the general atmosphere is impure, as is always the case in 
large cities, free ventilation should never be neglected; for, how- 
ever contaminated the external air may be, it soon becomes still 
more impure and insalubrious, by being breathed in a confined or 
stagnant state. The practice of using the nursery as a common 
sitting room, by the female portion of the family is extremely im- 
proper, — more especially when from the inclemency of the weath- 
er, the doors and windows cannot be kept sufficiently open, to se- 
cure a proper renewal and circulation of the air. Each individual 
exhausts the vivifying principle of nearly a gallon of air every 
minute: and the contaminating and putrescent exhalations which 
are continually issuing from the human body, constitute a source of 
rapid atmospheric deterioration. 

The observance of strict cleanliness, also, is indispensable to 
the preservation of a pure air in nurseries. The floor should be 
kept clean and dry; wet and soiled articles of clothing must not 
be suffered to remain in the room; and the child's excretions 
ought always to be speedily removed. " No food should be cook- 
ed in nurseries, if it can possibly be avoided; nor should linen be 
washed, dried or ironed there, as these processes tend to render 
the air offensive and impure. Hanging up the linen of children 
or drying their diapers in the place where they respire, produ- 
ces exhalations highly detrimental to their eyes, as well as inju- 
rious to the general health." No flowers ought to be cultivated 
in nurseries, since they not only tend to deteriorate the atmos- 
phere during the night, but often give out effluvia that are highly 
injurious to the animal economy. It need scarcely be observed 
that the burning of charcoal, out of the full draught of a good 
chimney, is always attended with the utmost risk of alarming or 
fatal consequences. 

There is no part of the management of nurseries more impor- 
tant in its consequences, than a proper regulation of the temper- 



OF AIR, &c. 57 

ature. The apartments of children are, in general, kept much 
warmer than is consistent either with comfort or health. Nothing 
tends more directly to enfeeble and relax the human body, and to 
predispose it to the injurious influence of cold and atmospheric vi- 
cissitudes, than habitual confinement in heated rooms. The cuta- 
neous and pulmonary exhalents, being kept, almost continually, 
in a state of inordinate excitement by the stimulus of the heat, 
acquire so great a susceptibility to the depressing influence of 
low temperature, that the slightest exposure to the open air, is 
apt to arrest their action, and to give rise to the various distress- 
ing and dangerous consequences of a suddenly checked perspira- 
tion. " Warm rooms," says Struve, " in my opinion, principally 
contribute to the extraordinary mortality of children, who are 
carried off by convulsions, in the first months of their lives. As 
they daily become weaker from the constant action of heat, every 
draught of air occasioned by opening the windows or doors is 
dangerous to their organs. It is an established fact, that in the 
proportion as we habituate ourselves to warm dress and heated 
apartments, so do we render the body more liable to be injured 
by exposing it to the influence of fresh or cold air." Children 
who are accustomed to immoderately warm rooms are seldom en- 
tirely free from coughs and colds during cold and humid weather; 
for as they cannot be always confined to their apartments they are 
unavoidably at times exposed to the impressions of cold air. As 
the continued influence of atmospheric heat has a very decided 
tendency to increase the irritability of the system — rendering it 
morbidly susceptible of the impressions of irritating causes, the 
practice of keeping the air of nurseries very warm is particularly 
detrimental to children during the period of dentition. Under 
the most judicious sanitary regulations, the systems of children 
are apt to acquire a morbidly irritable condition during this pro- 
cess. It is manifest, therefore, that when this natural tendency to 
an irritable habit, is promoted by the cause under consideration, 
the liability to disease must be peculiarly great. When we take 
into view the tendency which exists during dentition to a preter- 
natural determination of blood to the head, in connection with 
the general irritable and inflammatory condition just referred to, 
it is obvious that children who spent the greater part of their 
time in heated rooms, must be especially liable to inflammatory 
affections of the brain, from the occasional impressions of cold to 
which they are necessarily more or less exposed. 

The temperature of nurseries should never be suffered to ex- 
ceed 70° of Fahrenheit. In general a temperature of about 65° 
or 66°, is sufficiently comfortable; and experience has shown? 
that it is best adapted to secure the health and vigor of the 
human system. This moderate degree of heat does not favor 

I 



58 THE NURSERY. 

the generation of noxious effluvia from decompositions; nor doe9 
it impair the natural powers of vital resistance, to the injurious 
impressions of cold, or sudden transitions of temperature. Chil- 
dren who are accustomed to this temperate degree of warmth, 
may he taken into the open and cold air, without any peculiar 
risk of injury, from its sudden depressing influence. 



CHAPTER V. 

THE NURSERY. 



From what has already been said, in the preceding chapter, 
in relation to the great importance ol preserving a pure and fresh 
air in the apartments of children, it is obvious that a good nursery 
ought to be spacious, perfectly dry, airy, and elevated above the 
ground floor. In general these important requisites to the proper 
adaptation of nurseries for the purposes of comfort and health 
are too much neglected. Instead of selecting a large and airy 
apartment, the narrowest, most indifferent and cooped up room in 
the house is often appropriated to this purpose. It is very diffi- 
cult to preserve a proper degree of purity and circulation in the 
air of a small room, without subjecting its inmates to much incon- 
venience and risk of taking cold. From the smallness of the 
space, the air of such a room, soon becomes contaminated by 
breathing, perspiration and other unavoidable sources of impure 
effluvia. To preserve a sufficient degree of purity and freshness 
in the air, recourse must be had to frequent ventilation, by open- 
ing a window or door. A constant fluctuation of temperature is 
thus kept up in the apartment; and those who remain in it, are 
much exposed to the injurious influence of repeated currents of 
damp and cold air. These unfavorable circumstances are, in a 
great degree, obviated by a large and airy room. Ventilation 
need not be so frequently repeated, and may be performed with- 
out injurious vicissitudes of temperature, or direct exposure to 
strong and sudden draughts of cold air. Independent of the greater 
facility of keeping up a suitable degree of temperature, purity, 
and circulation in the air of spacious apartments, nurseries of 
ample dimensions are particularly desirable also on account of 
the opportunity which they afford to children of taking exercise, 
by running and jumping about on the carpet, " when the weather 
will not permit them to enjoy the advantages of the open air.'* 



THE NURSERY. 59 

A nursery consisting of two chambers opening into each other 
possesses many very important advantages over a single room. 
With such an arrangement the children may sleep in one room, 
and remain in the other while awake. They may thus enjoy 
the advantage of going to sleep in pure air; and of passing, in 
the morning, out of their bed-chambers, at once into the renewed 
and purified air of the other apartment. They may also avoid 
inconvenience and risk of injury, from the dust, currents of air, 
&c. which attend the sweeping, dusting, washing and ventilation 
of the nursery; for while these operations are going on in one 
room, they may retire into the other. 

With regard to the best means for warming nurseries, there 
exists some difference of opinion. Dr. Dewees objects to the use 
of stoves, because: " 1st, there is greater danger that the children 
may get severely burnt; 2d, they are almost always too much 
heated; 3d, they render the air too dry; 4th, the air is almost 
constantly injured by substances thrown upon the stove, as grease, 
meat, &c; 5th, there is always a temptation to do some kind of 
cooking upon or in the stove, to the annoyance of the comfort, or 
the injury of the health of the inmates, besides the serious risk 
of scalding by heating water upon it." Carelessness and im- 
proper conduct may, indeed, convert any contrivance for warm- 
ing apartments into a nuisance. Most of these objections apply 
with equal, if not greater propriety to open fires. The risk of 
injury from burns, is certainly quite as great from an open fire, 
as from a stove. How often do we hear of children receiving 
the most serious, and even fatal burns, from their clothes taking 
fire by coming in contact with open fires? The use of a good 
fender, will, doubtless, obviate the liability to this accident; but 
the risk of receiving burns from a stove may be quite as effectu- 
ally prevented by surrounding it with a proper railing — and this 
should always be done in apartments appropriated to children. The 
tendency of stoves to produce too great a dryness in the air may 
be readily counteracted by keeping a small basin of water slowly 
evaporating on or near the stove. The objection that stoves are 
apt to be kept too warm, is founded rather on the abuse than on 
any positive unfitness of this mode of heating rooms, and may be 
effectually obviated by proper care and management. The same 
observation applies to the other objections— namely that stoves 
are apt to be used for cooking; and that grease, meat and other 
substances calculated to give rise to offensive effluvia are often 
thrown upon them, and the air thereby rendered impure. Open 
fires, are, in truth, much more frequently used for cooking in 
nurseries, than stoves; and although much of the steam and 
effluvia may be carried up by the draught of the chimney, enough 
of them is in general diffused throughout the room, to give an 



60 THE NURSERY. 

unpleasant and unwholesome character to the air. Whether 
stoves or open fires be used, cooking ought never to be permitted 
in well-conducted nurseries. If rooms warmed by stoves are 
more liable to be heated to excess, open fires, on the other hand, 
are more apt to keep up an injurious variation of temperature. 
The preservation of a steadfast and uniform degree of warmth, 
throughout every part of the room is particularly desirable in 
nurseries. This is easily effected by means of a stove, however 
spacious the chamber may be. With an open fire, on the con- 
trary, it is always extremely difficult to procure a uniform temper- 
ature in large apartments; for while the air near the fire is 
uncomfortably warm, that of the remoter parts of the room is 
often disagreeably cold. Nevertheless, in small and confined 
nurseries, an open fire is upon the whole, preferable to a stove; 
for as the air of a small chamber is soon rendered impure by the 
breathing, perspiration, &c. of its inmates, a more regular influx 
and circulation of air is required, than in large rooms, to keep 
up a proper degree of atmospheric purity — and this is much more 
certainly obtained by the draught of an open chimney than by an 
ordinary close stove. 

The windows of nurseries should be provided with bars fixed 
across the lower half of them, in order to prevent children from 
falling out — an accident which is by no means uncommon, when 
this precautionary measure is neglected. They should also be 
supplied with shutters, particularly when they face the south, 
" that the room may be darkened, when the exclusion of light 
becomes necessary or proper." 

The floor of nurseries should be covered with a soft woollen 
carpet. This is especially proper, during early infancy; before 
children have acquired the full use of their legs, and while they 
are as yet subject to frequent falls and blows, in their feeble and 
uncertain efforts to move about the room. Children rarely 
receive any material injury from falling on a soft carpet: and 
when we advert to the very serious consequences which are apt 
to result from severe blows on the head during childhood, the 
want of carpeting must be regarded as a very considerable defect 
in a nursery. All superfluous furniture, should be excluded 
from the apartments appropriated to children. They should, 
however, be supplied with well-adapted contrivances for infantile 
amusement and exercise. A well-constructed rocking horse, 
usually affords children much delight combined with excellent 
exercise. 



OF WEANING. 61 



CHAPTER VI. 

OF WEANING. 

The period to which suckling may be extended without affect- 
ing the health either of the mother or infant is so entirely under 
the control of a variety of circumstances of an accidental charac- 
ter, that no particular term, of general applicability, can be assigned 
at which infants should be finally separated from the breast. In 
general, this important function is continued much longer, than a 
proper attention to these circumstances would justify; and the 
consequences of this error, are often of a very serious character. 
The only thing that is usually regarded by mothers, in fixing on 
the time for weaning, is the age of the infant. The child is suck- 
led until it attains a certain age, without any regard to the devel- 
opement of its digestive powers, or the state of its health and 
constitutional vigor. By this course, children may be kept at the 
breast, long after the vigor of the digestive functions, and the 
demands of the system require a more substantial and nutritive 
diet; and on the other hand, they may be separated from the 
breast, before the stomach has acquired sufficient energy to digest 
with due facility a stronger and less congenial aliment. The 
progressive developement of the digestive powers, and the 
demands of the organization in relation to nutrition, are very vari- 
ous among different infants. It is particularly important, that the 
condition of infants, with regard to these circumstances, should be 
consulted in regulating the period of lactation. The obvious 
correspondence which exists between the successive appearance 
of the teeth, and the developement of the digestive powers, 
affords us a safe guide in relation to this subject. The child 
comes into the world with teethless gums, and instinctive powers, 
adapted in the most perfect manner, for drawing its nourishment 
from the maternal breast. It is not furnished with teeth, because 
neither the mode in which its appropriate nourishment must be 
taken, nor the character of the nourishment itself requires such 
organs, nor are the powers of the stomach as yet sufficiently 
active, to digest, in a proper manner and without injury, the kind 
of food which would require the aid of teeth. After the lapse of 
some time, varying in different cases from about two to four or 
five months, the first two inferior cutting teeth protrude through 



62 OF WEANING. 

the gums. In the course of from four to six weeks afterwards, 
the two corresponding teeth of the upper jaw make their appear- 
ance. These, in three or four weeks, are succeeded by the lateral 
cutting teeth of the lower jaw; and in a few weeks subsequently, 
those of the upper jaw also make their appearance. 

Now, as in relation to their use, the teeth have a direct refer- 
ence to a more substantial aliment, than that which the stomach 
of the new-born infant is capable of digesting, we may reasonably 
infer, that the successive appearance of these accessary instruments 
of digestion, corresponds with the progressive developement of the 
important function which they are intended to subserve. Thus 
an infant that is furnished with four or more teeth, at the age of 
six months, may be presumed to possess more active digestive 
powers, and to require a more varied and nourishing food, than 
one, who, at the same age, is as yet destitute of these little instru- 
ments. When speaking of the nourishment of infants, it was 
remarked, that immediately after the first teeth have made their 
appearance, it will, in general, be proper to allow the child small 
portions of some of the blandest kinds of artificial food ; and that 
both the quantity and nutritious quality of the aliment should be 
gradually increased, in proportion as the teeth are successively 
protruded through the gums. By the time that all the cutting 
teeth have made their appearance, the child's digestive organs 
will have acquired sufficient tone and activity to enable them to 
digest, without difficulty, a simple and appropriate artificial diet; 
and the system, in general, will have attained a state of devel- 
opement which renders such a nourishment more suitable to the 
exigences of the organization, than the less substantial aliment 
derived from the maternal breast. 

This period then — namely soon after all the incisor teeth have 
made their appearance — ought to be regarded as the proper time 
for weaning, provided no adverse circumstances, either on the 
part of the infant or the mother, render it necessary to terminate 
lactation sooner, or to prolong it to a more advanced age. It is 
evident, that according to this rule, the proper period of weaning, 
must vary considerably in different cases. It will seldom, however, 
be delayed beyond the eleventh month, and in the majority of 
instances will occur between the ninth and tenth month. I am 
entirely persuaded, both by experience, and by what appear 
to be the obvious intentions of nature, that, if the duration of 
suckling were always regulated by this rule, no inconsiderable 
amount of sickness and constitutional infirmity, both in relation 
to the mother and the infant, would be avoided. 

Unless urgent reasons exist for an immediate separation of the 
infant from the breast, weaning ought always to be accomplished 
in a gradual manner. A sudden transition from the mild and 



OF WEANING. 63 

simple nourishment obtained at the breast, to the exclusive use of 
a more substantial artificial food, could rarely fail to produce 
disorder of the digestive organs and bowels, even in the most 
robust and healthy children. If the mode of management which 
has already been indicated, in relation to the nourishment of the 
child be adopted: — that is, if small portions of the most simple 
and bland kinds of artificial food be allowed after the first teeth 
have made their appearance, and its quantity and nutritious quality 
be gradually increased, in proportion as the other incisor teeth 
come out, the stomach will be sufficiently prepared when the 
proper period of weaning arrives, to admit of an immediate 
passage from the nourishment of the breast to an exclusive arti- 
ficial aliment, with but very little or no risk of unpleasant conse- 
quences. When the period of weaning is approaching small 
portions of bread, bread and milk, milk thickened with rice, or 
flour, rice, chicken, mutton or beef tea, &c, should be allowed 
the child, two or three times daily; whilst, at the same time, the 
intervals of suckling should be more and more prolonged. By 
this course of management the infant's stomach will be gradually 
accustomed to a more substantial nourishment, and its attach- 
ment to the breast insensibly diminished. When the child mani- 
fests great reluctance to a total separation from the breast, we 
may sometimes facilitate the weaning by applying some offensive 
substance to the nipples, such as aloes, infusion of colomba, or 
gentian, assafoetida, or a weak solution of sal ammoniac, &c. 
Some advantage may also be obtained by accustoming the child, 
to drink out of a tea-cup, saucer, or glass, and thus teaching it 
early, to receive its nourishment from vessels of this kind. 

After the child has been weaned its principal nourishment 
ought still to consist of liquid or semi-fluid substances. Milk, 
milk boiled with bread, or slightly thickened with rice or wheat 
flour, rice, preparations of arrow root, tapioca or sago, oatmeal 
gruel, pulverised crackers dissolved in warm water with a little 
milk and sweetened, should constitute the principal nourishment, 
until the eye teeth or fangs have made their appearance. Along 
with these fluid alimentary substances, small portions of bread, 
bread and butter, and weak and simple broths may be allowed 
occasionally, with perfect propriety. It is particularly important 
to guard against too full and nourishing a diet immediately after 
the weaning has been accomplished. Though gradually brought, 
in the way just stated, to bear the simpler kinds of solid nourish- 
ment when taken at distant intervals, the stomach is readily 
oppressed and disordered, at this period, if the transition to a 
substantial diet is abrupt. It will digest small portions of such 
food, without difficulty, when taken at considerable intervals; 
whilst a frequent and free use of the same articles, would soon 



64 OF WEANING. 

overwhelm and exhaust the digestive powers, and give rise to a 
train of distressing dyspeptic affections. The quantity of solid 
food should, therefore, not be materially increased immediately 
after weaning: nor should there be any particular increase in 
the general quantity of nourishment whether solid or liquid, 
until the stomach has been fully accustomed to the change. After 
the eye teeth have made their appearance, however, the solid 
and more nourishing kinds of food should be gradually increased, 
until the process of primary dentition has been completed — by 
which time, the powers of the stomach are, in general, sufficiently 
developed, to admit of a full and substantial aliment. 

Circumstances requiring a deviation from the above general rules 
for determining the duration of lactation. The progress of denti- 
tion is, doubtless, our safest guide, in regulating the nourishment 
of infants, and in deciding on the period, at which they may 
with propriety be put on the exclusive use of artificial food. Not 
unfrequently, however, circumstances of an irregular or morbid 
character, render it expedient, or even indispensable, to wean 
the child, before it has attained the age and organic developement, 
which, under ordinary circumstances would be deemed requisite 
to justify its final separation from the breast. 

1. The mother may be affected with some constitutional malady, 
which may so contaminate her milk, as to render it highly injuri- 
ous to the child's health, if she continues to nourish it at the breast. 
I have known several instances of extremely distressing affections 
in infants, obviously produced by the tainted milk obtained from 
nurses laboring under syphilis. Mothers, affected with scrofula 
in an active state, or with ulcerated cancer, should, on no account, 
suckle their infants. 

The mother may also be so exhausted and debilitated by an 
attack of some acute disease, and the depletory measures requisite 
to subdue it, that she cannot continue to suckle her infant, with- 
out increasing her prostration and superinducing a train of 
alarming and highly distressing affections. The same difficulty 
is apt to occur, in mothers of a feeble, delicate and nervous habit 
of body, particularly when the digestive powers are weak, or so 
disordered that nourishing and substantial aliment cannot be 
taken. Under these circumstances, suckling can seldom be con- 
tinued without producing the worst effects. The constant drain 
of the nutrient elements of the blood, through the breasts, causes 
a rapid increase of the debility, and gives rise ultimately, to a train 
of very distressing nervous affections, which cannot be removed 
or even materially mitigated so long as the infant is nourished at 
the breast. If the suckling be continued, the appetite and diges- 
tive powers fail; severe pains in the head ensue, the nervous 



OF WEANING. 65 

system becomes greatly disturbed; transient pains, alternating 
with spasmodic twitches or numbness, occur in various parts of 
the body; the debility and emaciation advance rapidly; a mul- 
titude of anomalous nervous affections constantly harass the 
patient; a most distressing sense of sinking and emptiness, is 
at times felt in the region of the stomach; the mind becomes 
disturbed and tormented often with an intense dread of dying,or 
a constant apprehension of some dreadful accident. At last 
delirium and even mania sometimes supervene. 

I have recently met with a striking example of this kind. The 
lady — always of an extremely delicate and feeble habit of body — 
was suckling a robust infant, about four months old, when I first 
saw her. Her digestive powers were very weak, and her general 
strength was so much impaired that she was obliged to remain, 
almost constantly, in bed. At times she experienced violent pains 
in different parts of the body — most frequently, however, in the 
back part of the head, and in one of the temples. Her whole 
nervous system was extremely excitable, and she suffered without 
intermission, a variety of exceedingly harassing nervous affections, 
Sometimes she felt a distressing sinking and emptiness in the 
pit of the stomach; at others, a general numbness extended itself 
throughout her extremities; often, she experienced alarming pal- 
pitation, and almost constantly complained of a benumbed feeling 
in the tongue, accompanied, occasionally, with an inability to 
swallow, and rapid spasmodic twitchings of the muscles of the 
face and extremities. These symptoms were attended with great 
mental disturbance — manifested by a constant and intense dread 
of dying, and great apprehensions of some overwhelming misfor- 
tune. Not the slightest advantage was obtained from medical 
treatment, although a great variety of means, apparently adapted 
to the case, were employed, with anxious diligence, for more 
than two months. She had repeatedly been urged to wean the 
infant which she continued to suckle, but always obstinately 
refused to comply with the request. At length, however, she was 
prevailed on to wean the cnild. In the course of three or four 
days, the symptoms under which she had so long suffered, evidently 
began to abate; and at the end of the third week, she was 
entirely freed of her harassing complaint. I have, indeed, often 
met with cases of a similar character, and the instances of very 
serious suffering and prostration among young and delicate moth- 
ers, from suckling, are probably of much more frequent occurrence 
than seems to be generally supposed. " Many young ladies," says 
a late writer, " on becoming mothers, are incapable of supporting 
the constant drain to which the wants of their infants subject 
them. They lose their good looks, become gradually weaker and 
paler, and as their strength declines, they become more and more 

K 



66 OF WEANING. 

afflicted with a variety of harassing nervous affections." Medi- 
cinal means are of no permanent advantage. They may procure 
more or less temporary mitigation of the symptoms, but they are 
wholly inadequate to the removal of the malady. Nothing but 
weaning will suffice — and the entire separation of the child from 
the breast, is generally soon followed by a progressive subsidence 
of the sufferings of the patient. But it is not simply on account 
of the mother, that weaning becomes indispensable, in cases of 
this kind; the welfare of the infant, also, is intimately concerned. 
In nearly all instances where lactation produces the pernicious 
effects just stated, before the regular period of weaning, the 
secretion of milk is much diminished in quantity, as well as 
deteriorated in quality; so that it is not only wholly insufficient to 
supply the wants of the infant, but moreover often decidedly in- 
jurious, in its effects on the infant's digestive organs and general 
state of health. 

The foregoing observations refer more particularly to the 
necessity of weaning at a comparatively early period after the 
child's birth, when from the mother's feeble and delicate condition, 
suckling gives rise to symptoms of exhaustion, and nervous disor- 
der. " Many mothers," says Dr. Hall, " are incapable of suckling 
longer than three or four months, without producing symptoms of 
undue lactation, or exhaustion. Delicate females who are enfee- 
bled by haemorrhage during parturition, or who have been freely 
depleted, and confined to a very simple and innutritious diet, in 
consequence of some inflammatory affection soon after confine- 
ment, frequently suffer much exhaustion from suckling." If, in 
the early period of lactation, the mother becomes progressively 
weaker, with loss of appetite, and increasing symptoms of nervous 
irritation without any obvious cause, we may suspect exhaustion 
from suckling as the immediate source of the illness; and should 
this be the case, nothing but an entire separation of the child 
from the breast will be adequate to restore her health. 

It has already been observed above, that suckling is in general 
continued much longer than is consistent with the welfare either 
of the mother or the child. On the part of the mother, the effects 
of unduly protracted lactation are sometimes extremely pernicious. 
We not unfrequently see women pale, debilitated, and constantly 
tormented with dyspeptic and nervous affections, suckling their 
infants for eighteen or twenty months, and occasionally much 
longer, without suspecting that their sufferings and ill-health, is 
the result of exhaustion, from the constant drain of the nutritious 
elements of the blood which is kept up by the suckling. To 
relieve this exhausted and disordered condition of the system, 
medical aid is usually resorted to, and tonics, antispasmodics, 
alteratives, and nourishing diet freely and perseveringly employed 



OF WEANING. 67 

— but always in vain, and often even, with manifest injury. At 
length, after the mother has been reduced to a state of great 
feebleness and general disorder of the vital functions, the child is 
weaned; and now, what might have been effected in a few weeks, 
by a timely separation of the child from the breast, can hardly 
be accomplished in many months, by the most judicious and care- 
ful remedial management. Thus irremediable constitutional 
infirmity and nervousness are sometimes produced at an early 
period of life, which, under a more rational and prudent course 
of management, in relation to the duration of suckling, might 
have been entirely avoided. 

Many mothers are able to suckle their children until they 
arrive at the proper period of weaning, without the least incon- 
venience, who, nevertheless, will suffer very serious derangements 
of health, when the nursing is extended considerably beyond the 
time, which nature points out as the proper period for terminating 
this important function. When lactation is prolonged, as it often 
is, until it becomes a source of morbid exhaustion, the first mani- 
festations of its injurious influence consist in an obvious increase 
of debility, attended with disagreeable sensations in the region of 
the stomach and head. The digestive powers soon become much 
enfeebled, and various distressing dyspeptic symptoms ensue; the 
countenance becomes peculiarly pale and languid; severe pains 
occur in the head, often confined to the posterior part, or to one side, 
and a tormentingpain also is usually felt, "just below the cartilages 
of the false ribs on the left side, or directly below the left breast." 
Connected with these symptoms, a state of chronic hysteria, or 
extreme and harassing nervousness almost invariably occurs. 
Palpitation of the heart and alarming paroxysms of nervous 
agitation come on, at uncertain intervals; more or less cough 
generally occurs; the mind becomes despondent, irritable, and in 
aggravated cases, sometimes, decidedly deranged. Added to 
these symptoms, there is always more or less emaciation; and 
ultimately night sweats with slight febrile irritation ensues. The 
bowels are usually torpid. In consequence of the enfeebled state 
of the digestive powers, nothing but the simplest and mildest 
articles of food can be tolerated by the stomach. Articles that 
are not easily digested, or such as are of an irritating character, 
seldom fail to produce severe pains and disturbance in the head, 
and various distressing sensations in the stomach and chest. "In 
this state of things," says Dr. Hall, " the patient is apt to try to 
support her strength by a generous diet and wine. This, however, 
is a vain effort. For the tone of the stomach is already enfeebled, 
and this organ is therefore altogether incapable of bearing the 
increased burthen thus put upon it; and wine only induces fever- 
ishness, or at least a false and temporary appearance of strength." 



68 • OF WEANING. 

I have thus been particular in describing the evil consequences 
which are apt to result in females of weak digestive powers and 
nervous temperaments, from unduly protracted suckling, because 
I am persuaded, that this subject is too much neglected, and that 
the instances of serious indisposition and suffering from this source 
of exhaustion, are much more common, than is generally supposed. 
The proper course of remedial management in such cases, consists 
in the immediate weaning of the child, in conjunction with the 
use of a mild, simple, and nutritious diet, and remedies calculated 
to restore the tone of the digestive organs and improve the alvine 
secretions. 

On the part of the infant, also, suckling when continued much be- 
yond the proper period, is apt to exert a highly injurious influence. 
It is well known, that after the eleventh or twelfth month, the milk 
almost invariably becomes diminished in quantity, as well as more 
or less deteriorated in quality; and in proportion as the lactation 
is protracted, so will it lose more and more its nutritious and 
wholesome character. In many instances indeed the milk begins 
to deteriorate as early as the ninth or tenth month, corresponding 
in this respect, with the proper period of weaning as it is usually 
indicated by the progress of dentition. That the child must be 
liable to sustain injury in its health, when nourished by milk thus 
depraved is very obvious; and the liability to disease from this 
source, must of course increase in proportion as the suckling is 
protracted. Children who are suckled an undue length of time, 
generally gradually lose their fresh and healthy appearance. The 
countenance becomes very pale and acquires a languid, fretful 
and sickly expression. The digestive powers are enfeebled — 
giving rise to acidity, flatulency, colic, vomiting and diarrhoea. 
In some instances, the abdomen becomes tumid, firm to the touch 
and tender, whilst the extremities are progressively emaciating. 
Strumous swellings are apt to appear on the neck or under the 
ears; and scabby erruptions on the head and face. It would 
seem too, that a very decided predisposition to convulsive affec- 
tions is often created by unduly continued lactation, and Dr. 
Morton has adduced a number of cases to show that it not only 
produces a strong predisposition to meningites, but frequently 
operates as a direct exciting cause of this dangerous malady. He 
states it as his conviction, founded on experience, " that if chil- 
dren be suckled for an undue length of time, that is, any period 
beyond nine or ten months, they will be peculiarly liable to be 
affected with meningites. Or that, should they not become 
affected with this disease, during or soon after the time that they 
are thus improperly suckled, they will, nevertheless, acquire 
therefrom, a predisposition to cephalic disease, at some future 
period of their lives; and finally, that the same injurious effects, 



OF WEANING. 69 

vvill take place in infants, if suckled by women who have been 
delivered an undue length of time, although the infants them- 
selves, may not have been at the breast for too long a time." 

In some instances, the milk loses its wholesome properties at an 
early period of lactation, without any very serious or obvious de- 
rangement of health in the maternal system. When this occurs, 
the infant, often, throws up the milk again, soon after nursing, 
and becomes harassed with colic, griping, acidity and diarrhoea, 
attended with paleness, debility, emaciation, and frequently with 
scabby eruptions about the face and head. If the child becomes 
affected in this manner, when nourished exclusively at the breast, 
we may presume, that the milk has become depraved and injuri- 
ous to its digestive organs. If any doubt exist as to the agency 
of the milk in the production of the disorder, the breast should 
be withheld from the child as long as can be done without any 
particular inconvenience to the mother, and artificial nourish- 
ment, or the milk of a nurse substituted. If the mother's milk 
has been the cause of the child's illness, an obvious abatement of 
the sympfoms will soon take place; and should this occur, the 
child ought to be gradually entirely separated from the maternal 
breast. 

Mental inquietude, deep grief or sorrow, and other violent affec- 
tions of the mind, have a strong tendency to deprave the milk. 
Women of a very nervous habit and an irritable temper, are pe- 
culiarly liable to those mental perturbations which are apt to de- 
teriorate this nutrient secretion. " Those mothers," says Dr. 
Struve, " who are so unfortunately situated that they cannot avoid 
provocation, grief, or sorrow, as well as others who possess an 
irrascible and bilious temperament, or are subject to great ner- 
vous debility, accompanied by great susceptibility of every stimu- 
lus, will confer no benefits on their children by presenting them 
with a corrupted milk, which cannot fail to injure their health, 
and lay the foundation of fatal maladies." 

The recurrence of the menses, during lactation, exerts, in many 
cases, a decidedly prejudicial influence on the properties of the 
milk, and often renders weaning necessary, long before the usual 
period of separating the child from the breast. I have, in several 
instances, where menstruation had returned as early as the sixth 
month, known the child to become extremely ill, evidently caused 
by the deteriorated character of the milk, in consequence of the 
renovated menstrual function, as was demonstrated by the speedy 
return of health, after weaning was accomplished. The reap- 
pearance of the menstrual evacuation, moreover, renders the lac- 
tescent female more liable to the recurrence of pregnancy — a con- 



70 OF WEANING. 

dition which invariably lessens the quantity of the milk, and in 
some instances deteriorates its quality. Neither the appearance 
of the menses, nor the occurrence of pregnancy during lactation, 
however, can be taken as a positive and constant indication of the 
propriety or necessity of weaning. Occasionally, infants are kept 
at the breast, while the catamenia are regularly recurring, and 
during the early period of pregnancy, without receiving the 
slightest apparent injury. The reverse nevertheless frequently 
takes place, and weaning becomes indispensable to the welfare 
of the infant. When therefore the mother finds the child becom- 
ing sickly, feeble, and annoyed with disorder of the stomach and 
bowels, after menstruation has returned, or after she finds herself 
in a state of pregnancy, and relief is not obtained, in due time, 
from the use of appropriate remedial means, the child ought to 
be gradually weaned. " Should a woman," says Dr. Morton, 
" with an infant at the breast, again become pregnant, one of two 
things will usually take place; either she will miscarry, or her 
milk will become impoverished in quality and diminished in quan- 
tity. It was not intended by nature that the processes of pregnancy 
and lactation should go on simultaneously; but, on the contrary, 
that the one should commence when the other had terminated; 
and experience sufficiently proves, that they will not proceed well 
together: the reason of which, as it appears to me, may be easily 
given. During pregnancy, and particularly during the latter pe- 
riods, the vessels of the womb gradually enlarge, and a much 
greater quantity of blood than usual is determined to that organ 
for the increase and perfection of the embryo, and its appendages; 
which after delivery becomes transferred to the breasts to supply 
the material for the secretion of the milk: but if during pregnancy, 
lactation be also persevered in, the blood becomes directed, at 
the same time, to two different parts of the body, somewhat re- 
mote from each other; and hence, neither is likely to receive its 
due proportion of this vital fluid, and consequently the functions 
of one or the other, or of both, are liable to become impeded or 
suspended. If the breasts continue to receive a sufficient quantity 
of blood, the secretion of milk goes on properly, but the womb is 
deprived of its necessary supply; the embryo, in consequence, 
languishes and dies, and, becoming an extraneous body, is thrown 
off, producing abortion: while, on the other hand, should the 
womb still obtain its due proportion of blood, the breasts are 
robbed of it, and the secretion of milk, if not altogether suppress- 
ed, is rendered either deficient in quantity or deteriorated in 
quality." 

If from causes of this kind, it occasionally becomes necessary to 
separate the child from the breast sooner than would otherwise be 
deemed proper, circumstances may also occur, which will render 



OF WEANING. 71 

it expedient to protract the duration of suckling, beyond the pe- 
riod that might be indicated by the progress of dentition, or the 
mere age of the infant. The child may be laboring under some 
disease, or it may be in a very debilitated condition from previ- 
ous disease — or its digestive organs may be weak and irritable, 
at the regular period of weaning. Under such circumstances, it 
would undoubtedly be improper to wean the child, unless good 
reasons existed for believing that the milk had become decidedly 
unwholesome. The bland and congenial nourishment obtained 
at the breast, could hardly be substituted by the mildest artificial 
food, without retarding the progress of the child's convalescence; 
and in a very debilitated condition of its digestive powers, 
such a transition could hardly fail to give rise to very serious 
affections. Children should never be weaned when they are sick, 
unless the indisposition is found to have been produced or to be 
supported by an unwholesome state of the milk (Dewees). 

Some attention should also be paid to the season of the year, 
in fixing on the period of weaning. In general, weaning may be 
accomplished with less inconvenience and risk of unpleasant con- 
sequences to the child, during the mild months of April, May, 
September, October, and the early part of November, than whilst 
the weather is inclement. Exercise in the open air, is always 
highly beneficial to the child, at the time of weaning. It tends, 
in no inconsiderable degree, to fortify the system of the child, and 
to enable its digestive organs to bear without inconvenience, the 
change of nourishment. In consequence of the peculiar tendency 
of warm weather to excite cholera infantum, particularly in cities 
or large towns, it is in general inexpedient to separate children 
from the breast, during the months of June, July and August; for 
it has been abundantly ascertained that the transition from the 
maternal milk to an exclusive artificial nourishment, during this 
season, has a decided tendency to favor the occurrence of this 
dangerous malady. Nevertheless, should the child be manifestly 
suffering from a deteriorated state of the milk, it ought to be sepa- 
rated from the breast, without any regard to season; for a bad 
condition of the milk, would doubtless, be more injurious in this 
respect than a suitable artificial nourishment. 



72 CLEANLINESS. WASHING. BATHING. 



CHAPTER VII. 

CLEANLINESS. WASHING. BATHING. 

The skin is one of the most extensive and important emuncto- 
ries of the human system. Through its countless pores, a large 
portion of the secrementitious elements of the body are continu- 
ally passing. Whatever interferes with the regular action of 
these emunctories, or impedes the free elimination of the perspir- 
able materials of the blood, becomes a source of more or less seri- 
ous disease; and on the other hand, every tiling that tends to 
maintain a healthy activity of this function, contributes, very large- 
ly to the preservation of a healthful condition of the system. 

Cleanliness is a most important requisite for keeping up a healthy 
state of the skin. When ablution is neglected or inadequately 
attended to, particles of perspirable matter, together with the 
dust which settles on the cuticle, insinuate themselves into the 
pores, and spread a film of impurities over the whole surface. 
This, not only interferes with the regular progress of the cutane- 
ous transpiration, but tends, moreover, in no slight degree, to dis- 
order the healthy structure of the cuticle and cutis, and, ulti- 
mately, to give rise to protracted and dangerous constitutional 
maladies. Children who are neglected in this respect, are much 
more apt to suffer severely from the contagious eruptive fevers, 
incident to childhood, than those whose skin is kept clean and 
pure. The tendency of a foul state of the skin, to give rise to 
various chronic cutaneous disorders, of a loathsome and harassing 
character, is well known. Itch, scabby eruptions on various parts 
of the body, tetrous affections, painful and offensive excoriations 
and herpetic disorders, are often the result of uncleanliness of the 
body. The general health, too, is liable to be impaired, by an 
habitually unclean state of the surface; and it unquestionably 
predisposes the system to the occurrence of indigestion, and other 
forms of gastric and intestinal disease. The agreeable feelings 
which entire cleanliness is calculated to produce, as well as the 
excellent moral influence which it is capable of exerting on the 
mind, are, in themselves, of sufficient moment to claim for it the 
most solicitous attention. Children, who are early accustomed 
to the comfortable and healthful impressions of washing and 
bathing, will rarely, in after life, neglect the observance of per- 
sonal cleanliness; and those, on the contrary, who are neglected, 



CLEANLINESS. WASHING. BATHING. 73 

in this respect, during childhood, will seldom manifest a proper 
regard for this physical virtue, in the subsequent stages of their 
lives. 

Infants ought to be thoroughly washed over the whole surface 
of the body once every day until they are weaned. After 
this period it will in general be sufficient to make the ablutions 
once every other day. The water ought to be warm during the 
first three or four months. It should then be reduced to luke- 
warm, and continued at this temperature until the progress of pri- 
mary dentition is completed, when it ought to be still further re- 
duced until it excites a decided sensation of coolness when first 
applied to the body. The washing should be performed with a 
soft sponge or a piece of soft linen; and particular care taken to 
remove the impurities which are apt to remain in the folds of the 
skin and joints. In addition to this indispensable means of pre- 
serving a pure and healthful condition of the skin, balking must 
not be neglected. The bath ought to be used every other day, 
during lactation, and afterwards at least twice every week. The 
regular use of the bath seldom fails to exert a highly salutary in- 
fluence on the system, and ought never to be regarded as super- 
fluous even as a means of cleanliness, however carefully the gen- 
eral ablutions be attended to. Until the end of the third year at 
least, the bath ought to be tepid; and for feeble and sickly chil- 
dren it will be proper to continue the use of tepid water for this 
purpose to a more advanced age. When the child is healthy and 
vigorous, however, the tepid, should be gradually substituted by 
the cool bath after the third year; though injury is, probably, 
much more frequently done, by too early a transition to the cool, 
than by too long-continued a use of the tepid bath. In using the 
bath, the child's body ought to be immersed up to the shoulders 
or neck. The practice of immersing only the lower half of the 
body in the bath, is decidedly objectionable. The upper part of 
the chest being wet, and exposed to the cooler temperature of the 
air, generally feels chilly or uncomfortably cold, while thus par- 
tially immersed in the tepid water — a situation which is well 
calculated to give rise to catarrhal and other inflammatory affec- 
tions of the respiratory organs. 

The time during which it may be proper to remain in the bath 
must be varied according to the age of the child. For the first 
four or five weeks, the infant should not be kept beyond two or 
three minutes in the bath — and the duration must, afterwards, be 
gradually prolonged, as the child advances in age, until it extends 
to twelve or fifteen minutes — a period which a child may, with 
propriety, be allowed to spend in the bath after it has attained 
the age of four years. 

It is to be particularly observed, that children should never be 

L 



74 CLEANLINESS. WASHING. BATHING. 

permitted to enter the bath while they are in a state of free per- 
spiration from exercise — a precaution which is especially impor- 
tant when the water is below the tepid temperature. 

The best time for bathing children is about two hours after 
breakfast or dinner. Infants should not be put in the bath imme- 
diately after having been freely nourished at the breast. To ob- 
viate the risk of taking cold, the bathing ought to be conducted 
in a room heated to a comfortable degree of temperature; and on 
removing the child from the bath, it should, without delay, be 
wiped perfectly dry, and immediately invested in warm and dry 
linen. " Infants may then be placed in bed, which in winter 
should be previously warmed ; and they will generally fall into a 
refreshing sleep, attended with a gentle and beneficial perspira- 
tion. Children, further advanced in age, who have already been 
accustomed to the cool bath, need not be put to bed, but rather 
induced to take exercise after it in the open air, though much 
depends here on the circumstance, whether they have been 
bathed in warm, cool, or cold water. If warm water has been 
used, the child should be immediately put to bed; for nothing is 
more apt to predispose to the injurious effects of cold than warm 
bathing." In that general tendency to increased perspiration 
which is produced by the tepid bath, every draught of air, and 
especially the sudden removal to a cold atmosphere, is peculiarly 
apt to give rise to catarrhal and other febrile affections. After 
cool-bathing, on the contrary, no apprehensions of injurious con- 
sequences need be entertained from exposure to the open air; 
and active exercise, after coming out of such a bath, exerts, in 
general, a very salutary influence on the health and feelings of 
the individual (Struve). " In rough weather, however, it is more 
advisable to keep the young party, after bathing, for half an hour 
in the nursery, where they may run about according to their own 
pleasure, and then enjoy the fresh air, but with strict injunctions 
not to sit down on the grass."* 

Some writers advocate the use of cool and even cold water, 
both for washing and bathing infants; and many mothers pursue 
this practice under the fallacious idea that it tends to invigorate 
the infantile system and fortify it early against the injurious influ- 
ence of cold and sudden changes of temperature. Reference is 
usually made to the custom, in some countries, of plunging new- 
born infants into cold water, as an evidence of the propriety and 
usefulness of this practice ; and it cannot be doubted, that of those, 
whose strong constitutional energies enable them to pass safely 
through this severe process of hardening, many mav ultimately 
be benefited by its inuring tendency. It is well known, however, 

* On the Domestic Education of Children. By C. A. Struve, M. D. 



CLEANLINESS. WASHING. BATHING. 75 

that many infants perish, at an early period, in consequence of 
this cruel and unnatural exposure; and that, in general, those 
only who are endowed with vigorous powers of life, are able to 
sustain its depressing influence, without injurious consequences. 
Warmth is peculiarly congenial to the physical habits and sensi- 
bilities of the infantile system. Until birth, the infant is surround- 
ed by a medium of the temperature of its own body; and there 
can be no doubt, that its sensibility to cold, for some time after 
birth, must be such as to render its impressions very distressing 
and painful. Cold is a sedative or debilitating agent, in its direct 
and essential operation on the animal system. The increased 
activity which sometimes follows the application of cold, is caused 
by the reaction of the vital powers, after their temporary de- 
pression; but when the system is feeble, the depression caused by 
the cold, is often so great, that the powers of life are incapable of 
developing a healthy degree of reaction, and more or less perma- 
nent prostration and disorder of the system, is the inevitable re- 
sult. Feeble and sickly children ought to be as little exposed to 
low temperature as possible, until, by a judicious course of man- 
agement, their systems are gradually inured to its chilling and 
depressing influence. The use of cold or even cool water, for 
washing and bathing very young infants of weak constitutional 
powers, is frequently attended with the most unhappy conse- 
quences, and always, with a great deal of suffering. Even robust 
and vigorous infants often manifest, by their screams, and their 
protracted paleness, shrunken appearance, and tremor of their 
bodies, the painful and depressing effects produced by being wash- 
ed in cold water. Instead of being invigorated, they are fre- 
quently enfeebled by this practice; and before they become in- 
ured to the impressions of the cold or cool water, serious catarrhal, 
febrile, or bowel affections may be caused by its tendency to 
check the perspiration, destroy the regular balance of the circu- 
lation, and depress the vital powers. By the use of tepid water, 
on the contrary, the cutaneous exhalents are gently excited, with- 
out the risk of suspending their action, or of causing a sudden and 
dangerous revulsion of blood from the surface to the internal 
organs; at the same time, that the congenial temperature of the 
bath, produces an agreeable and salutary excitement throughout 
the whole system. In urging the propriety of using tepid, in pre- 
ference to cool water, however, it is proper to observe that the 
employment of decidedly warm water for bathing children, is not, 
in general, advisable, except during the first few weeks after 
birth, or as a remedial agent, in certain states of feebleness and 
disease. Warm bathing, by its tendency to over excite the ex- 
halents of the skin, is apt to produce a state of general relaxation 
and languor, unfavorable to the regular performance of the vital 



76 CLEANLINESS. WASHING. BATHING. 

functions, and to predispose the system, very strongly, to the inju- 
rious influence of cold. Children, who are often bathed in warm 
water, are apt to acquire a susceptibility to the impressions of low 
temperature, which renders them much more liable to catarrhal 
and other affections, from exposure to the open and cold air, than 
those who are habitually bathed in tepid or lukewarm water. As 
a general rule, the temperature of the bath ought to be about 98° 
of Fahrenheit during the first ten or twelve days. It should then 
be progressively reduced, about one degree every month, until the 
end of the first year, and continued at this degree of warmth until 
the completion of the second year. After this period the tempe- 
rature must be further lowered, though in a very gradual manner, 
until about the end of the third year the bath creates a sensation 
of decided coolness. In relation to this subject, however, regard 
must be had to the particular condition of the child with regard 
to its constitutional vigor, predispositions, and health. Weak and 
sickly children, generally require a greater degree of warmth, 
and a more cautious transition to cool bathing than such as are 
robust and healthy; and this observation is especially applicable 
to those who are strongly predisposed to bowel complaints, or to 
cutaneous eruptions. 



BOOK II. 

OF THE DISEASES OF CHILDREN. 



CHAPTER I. 

OF SYNCOPE, ASPHYXIA, AND IMPERFECT RESPIRATION. 

In the majority of instances, the child begins to breathe and 
cry, and the various functions of independent life commence their 
circle of action, as soon as it is ushered into the world. This, 
however, is not always the case. Many children manifest no 
signs of animation when born, in whom, nevertheless, the spark 
of life still lingers, and may, occasionally, be re-excited by prompt 
and judicious management. This state of apparent death, may 
depend either on an apoplectic condition, or on syncope, or on 
great feebleness and exhaustion of the vital powers. When it 
depends on an apoplectic state of the brain, the infant's counte- 
nance exhibits a livid or deep red and bloated appearance — the 
prolabia are purple or almost black, the eyes prominent, and the 
surface of the body warm, reddish and somewhat tense. This 
condition generally arises from a tedious and difficult passage of 
the infant's head through the pelvis, and particularly from the 
umbilical cord being wound tightly round the child's neck, impe- 
ding the return of the blood from the head, and thereby causing 
inordinate sanguineous congestion in the brain. This apoplectic 
condition is produced, also, by the unceasing and vehement ute- 
rine contraction, which is often excited by ergot; for infants who 
are still-born, or in a state of asphyxia, after the efficient adminis- 
tration of this substance, generally exhibit very strong marks of 

77 



78 OF SYNCOPE, &c. 

excessive vascular turgescence in the head. Indeed, it is difficult 
to conceive, how a long-continued and powerful action of the 
uterus could fail to produce dangerous or fatal sanguineous con- 
gestion in the brain. The water, by which the foetus is surround- 
ed, being wholly incompressible, the entire force of pressure ex- 
erted by the womb, must necessarily act directly upon the child, 
and cause so great a compression of the more yielding parts of the 
body, as nearly to arrest the circulation in them — the inevitable 
consequence of which must be, an excessive accumulation in the 
brain, heart and lungs, parts that are protected against external 
pressure, by the bony walls which enclose them. This is proba- 
bly the ordinary manner in which ergot, when exhibited under 
circumstances unfavorable to the speedy completion of labor, 
proves injurious or fatal to infants. 

In some instances of this kind, the child is born without any 
manifestations of life whatever. Its face is swollen and livid, tbe 
body flaccid, and the navel string has ceased to pulsate. Although 
but very little hope can be entertained of recovering an infant in 
this condition, it ought not to be immediately abandoned without 
making suitable efforts for the resuscitation of its vital powers. 
As almost every thing, in such cases, depends on the speedy re- 
moval of the congested condition of the brain, the umbilical cord 
should be immediately cut, and an effort made to strip some blood 
from it with the fingers. It is but very rarely, however, that any 
blood can be obtained in this way, and never after the heart has 
ceased to pulsate. I think it probable, that a sufficient quantity 
of blood might be abstracted, by dividing the cord within about 
an inch of the umbilicus, and applying a wide-mouthed cupping- 
glass, furnished with an exhausting pump, over the navel and its 
short portion of cord. By exhausting the cup, the blood would, 
doubtless, flow from the extremity of the cord, even perhaps, after 
the heart had ceased to act; and it appears to me not unlikely, 
that a considerable influence might, thus, be exerted in re-exci- 
ting the circulation. The child's head should be supported in an 
elevated position, and the inferior parts of its body wrapped in 
dry and warm flannel. In conjunction with these measures, an 
effort should be made to excite the respiratory function, by arti- 



OF SYNCOPE, &c. 79 

ficial inflation of the lungs, and compression of the thorax with 
the hands, so as to imitate the alternate acts of inspiration and 
expiration. In inflating the lungs, the accoucheur must apply his 
mouth to that of the infant, at the same time closing its nostrils, 
and endeavor, by a moderate but uniform force of insufflation, to 
fill its lungs with air. During this effort, the child's chest should 
be a little raised, and its head slightly thrown backwards, to 
facilitate the entrance of the air into the larynx. Dr. Dewees 
says, that the attempt to expand the lungs must be by a '•''forcible 1 '' 
insufflation — an advice which may readily lead to very unfortu- 
nate consequences. It appears, from a series of experiments, 
made a few years ago in France, on animals, and from observa- 
tions relative to the human subject, that no very great force of 
insufflation is necessary, to rupture the delicate air cells, and 
cause a fatal emphysema of the pulmonary structure. In sheep, 
and in the dead human subject, the air cells were ruptured by a 
force of insufflation, not greater than that which may be made by 
a person of ordinary respiratory vigor, without any very violent 
effort. 

It is not improbable, I think, that " forcible" efforts to inflate 
the lungs of infants born in a state of asphyxia, has often resulted 
in fatal rupture of the pulmonary air cells. To obviate this very 
unfortunate accident, the air ought to be thrown into the respira- 
tory passages, through a silk handkerchief folded double, or a fine 
napkin, laid over the mouth of the infant. This, I am persuaded, 
is a very useful precaution, and should never be neglected, when 
artificial inflation of the lungs is attempted. Of the tendency of 
forcible insufflation to rupture the air cells of the lungs, I had a 
very striking illustration, a few years ago. I attended a lady in 
a tedious and rather difficult labor. The child was still-born; but 
I nevertheless made some efforts to effect a resuscitation. I in- 
flated the lungs in the usual way. The child, however, did not 
recover. A singular tumor situated just above the middle of the 
left clavicle, induced me to ask permission to examine it with the 
scalpel. The tumor extended a short distance into the thorax, in 
following which, I opened the chest. On raising the sternum, I 
found the superior portion of the left lung in a complete state of 



QO OF SYNCOPE, &c. 

emphysema, and a good deal of air diffused under the anterior 
and lateral surface of the pulmonary pleura. With the exception 
of the inferior portions, both lungs were crepitous, and appeared 
to have been well inflated. That the emphysema was the result 
of rupture of the air cells, caused by the forcible inflation, and 
not of putrefactive decomposition, I could not doubt; for up to 
within about two hours of the termination of the labor, the child's 
motions were distinctly felt both by the mother and myself. 

When the umbilical cord continues to pulsate, in infants, born 
in this apoplectic or oppressed condition, relief may, in general, 
be speedily obtained, by promptly dividing the cord, and suffering 
more or less blood to flow from it. When the cord beats vigor- 
ously, nothing more is, generally, required for setting the vital 
functions in play, than the prompt abstraction of blood in this 
way. As the blood flows, the lividity and turgid state of the 
countenance, usually, disappear, and in a short time the infant 
begins to breathe. The efficacy of this measure may, in general, 
be enhanced, by supporting the infant's head in an elevated posi- 
tion, applying cool water to the scalp, and immersing the inferior 
extremities and hips in the warm-bath. 

When the pulsation of the cord is slow and feeble, inflation of 
the lungs is frequently requisite, in addition to the abstraction of 
blood in the way just mentioned, in order to excite the respiratory 
organs into action. Artificial respiration, however, is very rarelj 
capable of procuring any decided advantage in cases of this kind 
unless aided by the loss of blood. Whenever the face is turgid 
and livid, accompanied, as is usually the case, with signs of gen- 
eral sanguineous repletion, bleeding from the divided cord, is a 
measure of paramount importance. It is proper to observe, how- 
ever, that in cases unattended with these manifestations of cepha- 
lic congestion and general fulness — that is, when the face and 
body present a pale and shrunken appearance, blood cannot be 
abstracted without incurring much risk of injury. 

Some infants, who are ushered into the world with great rapid- 
ity, by a quick succession of vehement parturient contractions, 
remain for a minute or two without any, or but a few, imperfect 
respiratory efforts, although they will open their eyes and move 



OF SYNCOPE, &c. 81 

their extremities with sufficient activity. A few drops of cold wa- 
ter sprinkled on the chest and abdomen, will instantly cause them 
to breathe and to cry out lustily. The main point of caution, in 
cases of this kind, is to avoid tying the cord until its pulsation has 
ceased, or has become quite feeble. The pulsation, in these 
cases, is always very strong, and generally continues longer than 
in ordinary instances. I have known the respiration to become 
immediately much embarrassed and the face to assume a livid 
aspect, on the application of a ligature to the cord, while pulsa- 
ting actively, although the child had previously breathed and 
cried very strongly. 

In all instances where respiration does not ensue, or is embar- 
rassed, immediately after birth, prompt attention should be paid 
to the speedy removal of the viscid mucus which is usually lodged 
in the mouth, fauces, and larynx, of new-born infants. In many 
cases, breathing is much impeded by this cause; and in some in- 
stances, the quantity and viscidity of the mucus is so great, as en- 
tirely to obstruct the entrance of the air into the lungs. To 
dislodge this mucus from the fauces, a finger surrounded with a 
piece of soft linen, should be carefully introduced, and the tena- 
cious slime brought away from the posterior part of the mouth. 
The child should then be turned with its face downwards, and 
the body raised higher than the head. In this position, the child's 
back (between the shoulders) should be patted with the hand, 
and its body gently shaken, " so as to disengage any mucus that 
may be lodged in the trachea, and permitting it to flow out of 
the mouth, by making this the depending part" (Dewees). 

Infants are sometimes born in a state of asphyxia, without any 
signs of cerebral congestion or vascular fulness; the surface of 
the body being pale, and the face free from the puffiness which 
occurs in the apoplectic or congestive cases. If, in instances of 
this kind, the cord continues to pulsate, it must, on no account, be 
divided, until the pulsation has ceased. The viscid mucus should 
be immediately removed from the fauces and larynx, in the man- 
ner just mentioned; and a little cold brandy, spirits, or even 
water, dashed on the pit of the stomach. This, almost always, 
immediately excites the respiratory actions; and nothing further 
is necessary, until the pulsation of the cord has ceased, when it 

M 



82 OF SYNCOPE, &c. 

must be divided, and the child suffered to remain quiet, until its 
strength is in some degree recruited. Should these measures fail 
to excite the respiration, which however rarely happens, so long 
as the cord beats actively, advantage may sometimes be obtained 
from the application of some volatile stimulant to the nostrils and 
lips — such as brandy, hartshorn, spirits of camphor, or ether. It 
will, also, be proper to rub the body and extremities, gently, with 
dry warm flannels. If, notwithstanding the employment of these 
means, respiration do not commence, while the pulsation of the 
cord becomes more and more feeble, or wholly arrested, the 
chance of ultimate success must be regarded as exceedingly slen- 
der. When the pulsation of the umbilical cord has ceased, and 
the child is flaccid, every effort must be made to keep up the na- 
tural temperature of the body, by the external application of 
warmth, and to excite the respiratory function by artificial infla- 
tion. The cord must be divided, and the infant wrapped in dry 
and heated flannel. I agree, perfectly, with Dr. Dewees, in giv- 
ing a preference to dry warmth, by heated cloths, over the warm- 
bath. Experience has convinced me, that the former is a much 
more efficient means, for imparting warmth and exciting the fee- 
ble remains of vitality than the latter. It seems probable that, 
water may, in some degree, counteract the exciting effects of 
warmth, by its strong tendency to abstract the electric fluid from 
the body. Flannel, being a very imperfect conductor both of 
electricity and heat, is, doubtless, the best medium, in cases of 
this kind, for applying warmth to the body. The heated cloths 
ought to be frequently renewed, so as to keep up a uniform tem- 
perature, and their application continued as long as there may be 
any hope of ultimate success. At the same time that warmth is 
thus diligently imparted to the infants body, the efforts to excite 
respiration by alternately inflating the lungs and compressing the 
chest, in the way mentioned above, should be regularly and cau- 
tiously persisted in until the child begins to breathe, or there is 
reason to think that all further exertions must necessarily prove 
fruitless. Infants, in this condition, should not be hastily aban- 
doned. I have in several instances known more than thirty min- 
utes to pass under the employment of these resuscitating means, 
before the child began to respire; and cases have occurred in 



OF SYNCOPE, &c. 83 

which resuscitation was effected after a much longer period of 
exertion. 

Dr. Underwood thinks that the electric influence might he ad- 
vantageously employed in cases of this kind : and, from the extra- 
ordinary tendency of galvanism to excite muscular action, even after 
the animal functions are entirely abolished, it can scarcely be doubt- 
ed that much benefit might sometimes be derived from this active 
and pervading agent. This, however, is one of those means, which 
though capable perhaps, of doing much good, can very rarely be 
brought into use, on account of the delay which must necessarily 
always occur in procuring the apparatus and putting it in action. 

Respiration generally commences by a short and deep spasmodic 
inspiration or sob, which, at first, recurs at considerable intervals, 
becoming, gradually, more and more frequent and complete, until 
the respiratory function is established. Occasionally, however, 
instead of a progressive improvement in the action of the lungs, 
the respiratory efforts become more and more imperfect, after the 
first two or three forcible sobs, until the vital actions are entirely 
arrested, notwithstanding the continued exertions to excite and 
support them. Sometimes the respiration, when established, is 
for several hours so feeble, that the slightest fatigue or agitation 
is apt to arrest it, and exhaust the languid powers of life. In all 
instances, where a resuscitation has been effected from a state of 
asphyxia, it is of the utmost consequence to suffer the infant to 
lie perfectly at rest, for several hours, before it is subjected to 
the agitation and fatigue of washing and dressing. When the 
respiration is very feeble, a strict attention to this precaution is 
indispensable to ultimate success. There can be no doubt, that 
many infants have died in consequence of the fatigue and pros- 
tration caused by washing and dressing, during the very feeble 
and exhausted condition which often succeeds recovery from a 
state of apparent death immediately after birth. An instance of 
this kind occurred to me about six years ago. The infant was 
born in a state of asphyxia. Its face was neither livid nor bloat- 
ed, and the cord pulsated feebly. By the employment of the 
usual resuscitating means, it soon began to breathe, but in a very 
weak and sobbing manner. I had it wrapped in warm flannel 
and laid on a bed. By the time I left the room, its breathing had 



84 OF SYNCOPE. &c. 

become regular, and it made some feeble attempts to cry. I earn- 
estly enjoined that it should be left perfectly at rest, until I called 
again. I had not left the house more than an hour, before I was 
hastily summoned to visit the infant, with a message that it was 
dying. The child was dead before I arrived. I learned that as 
soon as I had left the house, the grandmother of the infant insist- 
ed that agitation and motion would " stir up life," and proceeded 
forthwith to wash and dress the infant in no very gentle manner. 
The immediate result was fatal exhaustion. It is of great impor- 
tance, also, to continue the external application of warmth until 
the respiration is fully established, and the child is able to cry out 
strongly. In applying the heated cloths, however, care should 
be taken to agitate the child's body as little as possible. Some 
advantage may be obtained from applying a few drops of warm 
wine and water to the infant's lips and nostrils; and I have known 
manifest benefit derived from gently washing the face with a very 
weak mixture of warm spirits and water. 

The preceding observations relative to the prostration which 
often succeeds recovery from a state of apparent death, are equally 
applicable to infants born in a very feeble condition, and to the 
majority of those who are born prematurely. Rest and warmth, 
in such cases, are all-important requisites for the gradual devel- 
opment of the vital functions. Infants born between the seventh 
and eighth month, generally remain in a somnolent state, for sev- 
eral weeks, and ought to be as little disturbed by washing, dress- 
ing, feeding, or in any other way, as possible. When they are 
very feeble, it will be most prudent to leave them perfectly at 
rest, for several days before they are subjected to the fatigue of 
washing and dressing. Dr. Dewees mentions two children born 
a little after the sixth month, who were neither washed nor dress- 
ed " for many days," and both recovered. 

Occasionally, feeble infants — particularly such as are much 
exhausted in consequence of a partial separation of the placenta 
or compression of the cord during labor, suddenly sink into a 
state of apparent death or syncope after respiration has been fully 
established and every thing seems to go on in a favorable man- 
ner. Without any obvious cause the infant becomes pale, cold, 
flaccid, the breathing very feeble and interrupted, and finally 



OF SYNCOPE, &c. 85 

wholly arrested; the countenance shrunk, the eyes fixed and half 
open, the hands livid, and the pulse extinct (Dewees). This death- 
like condition usually continues a few minutes, and then gradu- 
ally passes off, leaving the child in a languid and fretful state 
for many hours. These attacks are apt to recur at uncertain 
intervals, " unless the disease be arrested by suitable remedies, 
or death closes the scene." The few instances of this affection 
that have come under my notice, were attended with manifest 
disturbance in the alimentary canal; and Dr. Dewees observes 
that " a small quantity of very green fluid is almost always dis- 
charged from the bowels during the fit." In one of the cases I 
witnessed, several copious discharges of a thin dark-green matter 
occurred, immediately after the attack had subsided. The affec- 
tion is doubtless the result of intestinal irritation, in conjunction 
with a feeble and irritable condition of the system; and we accor- 
dingly find, that the employment of remedies calculated to correct 
the functions of the liver and intestinal canal, rarely fails to prevent 
a recurrence of the attack. During the paroxysm, efforts must 
be made to re-excite the vital powers, by a prompt recourse to 
external stimulating applications. The child's body should be 
wrapped in a piece of thick flannel wrung out of hot whiskey or 
brandy; a little warm water and wine may be thrown into the 
rectum; and a drop of ether, spirits of camphor, or sharp vinegar, 
should be applied to its nostrils and lips, and weak sinapisms laid 
on the soles of the feet. Under the influence of these exciting 
applications, the suspended functions of life usually return, in a 
gradual manner, until the action of the heart and lungs are fully 
re-established. To prevent the recurrence of the affection, re- 
course must be had to remedies calculated to correct the func- 
tions of the liver and alimentary canal. A few minute doses of 
calomel — that is, from one sixth to a fourth of a grain, given in 
the evening, and followed on the succeeding morning, by four or 
five grains of rhubarb, or a teaspoonful of castor oil, generally 
produces an excellent effect in such cases. Great care must also 
be taken to prevent the infant from over-distending its stomach 
with nourishment. 

With regard to the proper time for tying the umbilical cord, 
writers have expressed different opinions. Baudaloque, Denman, 



86 OF SYNCOPE, &c. 

White and Dewees, maintain that " we can never safely depart 
from the rule, that 'the cord is not to be tied until the pulsations of the 
umbilical arteries have ceased." Mr. Burns, on the other hand, ob- 
serves, that " when the child is vigorous and cries lustily, there 
is no occasion of delay in tying of the cord until it has ceased to 
pulsate." That very serious injury may result to infants from 
tying the cord, whilst it pulsates actively, even when the respira- 
tion is fully established, does not admit of a doubt; and, although 
the cord may, in general, be tied without the slightest unpleasant 
consequences in vigorous infants breathing freely, after its pulsa- 
tion has become decidedly feeble, — yet, as a general rule, it is un- 
questionably safest to delay the tying, until the cord has entirely 
ceased to pulsate. When the cord is tied whilst pulsating 
strongly, the breathing, sometimes, instantly becomes irregular, 
catching and feeble, and the countenance turgid and livid. Some 
years ago, I witnessed a striking instance of the evil effects which 
may be produced by the premature ligature of the cord. The 
infant breathed freely and cried out lustily, as soon as it was 
born. I waited three or \ four minutes, until the cord pulsated 
feebly, and then tied it. As soon as the ligature was drawn, the 
breathing became catching, irregular, and in a few moments 
almost wholly suspended, and the lips acquired a deep livid hue. 
I immediately divided the cord below the ligature, but obtained 
only a few drops of blood from it; and it was with the utmost 
difficulty, and only in a very gradual manner that the action of 
the lungs and heart were fully re-established. 

Injury may also result to the child, from too long a delay in 
putting a ligature on the cord, or separating it from the placenta. 
When the uterus contracts very powerfully soon after the birth 
of the child, the blood contained in the placenta, may be pressed 
out of it, as from a sponge, and engorge the vessels of the infant 
to a degree which may prove highly injurious and even fatal. I 
am convinced that I have seen several instances of alarming con- 
sequences from this cause, after the employment of ergot for hast- 
ening the labor. When ergot is given in the latter stage of labor, 
the womb is apt to contract with great energy upon the placenta, 
immediately after the expulsion of the infant; and it cannot be 
doubted that, when this takes place, the blood contained in the 



OF ASPHYXIA, &c. 87 

placenta must be more or less powerfully forced into the vascular 
system of the infant. I have known an infant to breathe and cry 
strongly for a short time, and then, suddenly, on the occurrence 
of a strong uterine pain or contraction, to fall into an oppressed 
condition, with a turgid and livid countenance, and feeble, inter- 
rupted and suffocative respiration, and a state of apparent insen- 
sibility. When, after respiration has been established, and the 
cord remains united, phenomena of this kind supervene, the cord 
ought to be immediately divided, and the blood suffered to flow 
until the symptoms of oppression are removed. 



68 OF THE MECONIUM. 



CHAPTER II. 



OF THE MECONIUM. 



The foecal matter formed in the bowels of infants, before birth, 
is called meconium, and consists of a dark green, yellowish, or 
party-colored residual substance of a viscid and semi-fluid consist- 
ence. When this recrementitious matter is retained in the bowels 
of the new-born infant, it seldom fails to give rise to intestinal 
irritation, and more or less general disorder of the system. Ex- 
hausting and painful diarrhoea, colic, mucous inflammation of the 
intestines, obstinate jaundice, convulsions, trismus, induration and 
enlargement of the mesenteric glands and consequent wasting of 
the body, disease of the liver, erysipelas with induration of the 
subcutaneous cellular tissue, not to mention other forms of dis- 
tressing and dangerous disease, may, it is believed, arise from the 
irritation occasioned by meconial matter in the alimentary canal. 
The timely removal of this substance from the bowels, is there- 
fore an object of no small degree of importance. Nature, in gen- 
eral, furnishes the appropriate purgative for this purpose, in the 
first milk or colostrum, secreted in the maternal breasts; and, in 
many cases, nothing more is necessary for the expulsion of the 
meconium, than the early application of the infant to its mother's 
breast. The small portion of fluid which the child, usually, ob- 
tains at the breast, during the first nine or ten hours, possesses a 
decidedly purgative character, and generally causes the entire 
evacuation of the meconial matter. As the colostrum is formed 
before the proper milk begins to be secreted, the child ought to 
be early put to the breast, in order to obtain this purgative fluid, 
before it becomes diluted and weakened by the milk. When the 
first suckling is delayed until the breasts are filled with the lacte- 
ous secretion, the bowels frequently remain unmoved, and recourse 
must be had to other means for removing the meconium. There 



OF THE MECONIUM. 89 

can be no doubt, that, in general, the colostrum is fully sufficient 
for effecting the expulsion of this substance from the bowels; and, 
as it was evidently intended for this purpose by the author of na- 
ture, it must be regarded as decidedly the most appropriate 
means for freeing the infant from this source of intestinal irrita- 
tion and disease. The practice of at once resorting to purgative 
remedies for the removal of the meconium is highly reprehensi- 
ble. Instead of putting the child early to the breast, and waiting 
for the operation of the congenial laxative prepared for it by na- 
ture, the almost universal custom is, to introduce some purgative 
substance into its stomach, such as castor oil, syrup of rhubarb, 
senna tea, magnesia, sweet oil, manna, or molasses, as soon as the 
infant is washed and dressed. When we reflect, that the stomach 
of the new-born infant has as yet never experienced any foreign 
impressions, and must necessarily be extremely delicate and sus- 
ceptible, the impropriety of introducing such irritating articles 
into it, immediately after birth, and before the digestive powers 
have been brought into action, appears very obvious. The stom- 
ach is thus often thrown into a state of severe irritation and func- 
tional derangement, which if it does not lead to speedy death, 
never fails to give rise to a train of extremely harassing conse- 
quences. Long experience has fully convinced me, that the dis- 
tressing dyspeptic affections— the colic, acidity— painful diarrhoea, 
and general sickly condition, so frequently met with during the 
first five or six months of infancy, very often have their origin in 
the gastro-intestinal irritation, caused by the purgatives employed 
for evacuating the meconium. The purge, given for this purpose, 
acting on the delicate and highly sensitive stomach, weakens, at 
once, its digestive energies; the very first nourishment that is 
taken, is, therefore, but imperfectly digested; more or less fer- 
mentation, consequently, occurs in the prima? vis, by which acid 
and other irritatory matters are generated, and additional sources 
of gastric irritation furnished. Unless judicious dietetic and other 
remedial measures be immediately adopted, a train of painful 
dyspeptic and general irritative affections will ensue, and soon 
acquire an ascendency, which can seldom be wholly subdued 
during the period of infancy. 

Although the undue retention of meconial matter in the bowels, 

N 



90 OF THE MECONIUM. 

is certainly very apt to prove detrimental to the health of the in- 
fant, yet it is by no means necessary to resort at once, to the use 
of purgative remedies for its removal. It was undoubtedly the 
design of the Creator, that this office should be performed by the 
colostrum; and there need be no harm apprehended, from the de- 
lay, which a dependence on this purgative secretion may require. 
Instead of giving to the infant an artificial laxative, let it be early 
applied to its mother's breast before the proper milk is secreted, 
and in nine cases out of ten, adequate purgation will be produced, 
without the slightest risk of injurious irritation of the stomach 
and intestinal canal. When the colostrum or first milk fails to 
produce the desired effect, recourse should, unquestionably, be 
had to artificial means for expelling the meconium from the bow- 
els; and for this purpose a teaspoonful of molasses diluted with a 
small portion of warm water, or a solution of manna, or a tea- 
spoonful of cold-pressed castor oil, should be given and repeated 
until the requisite evacuations have been procured. Rapid and 
free purging, however, is improper. A moderate action of the 
bowels, procured by gentle means, is fully adequate, in a great ma- 
jority of cases, to dislodge and remove the meconial matter in due 
time. It is of importance, however, to keep up a moderate de- 
gree of purgation until the meconium is completely removed; for 
the retention of even small portions of this substance, may ulti- 
mately give rise to very unpleasant consequences. 

Sometimes, though very rarely, cases occur in which very great 
difficulty is experienced in exciting an efficient action of the bow- 
els. In such cases purgative enemata ought to be employed, in 
conjunction with laxatives administered in full and repeated doses, 
until the requisite effect is produced. Dr. Dewees, relates a re- 
markable instance of intestinal torpor of this kind, in which, after 
frequent doses of castor oil and magnesia with injections of various 
kinds and the warm bath had been used without any advantage, 
relief was ultimately obtained from a grain of carbonate of soda 
administered every fifteen minutes until ten grains were taken. 
In a few very obstinate cases of this kind, I have succeeded well 
with a mixture of Ipecacuannha and rhubarb assisted by purga- 
tive enemata. Two grains of ipecac, with five grains of powdered 
rhubarb, may be given every hour until free evacuations are 






OF THE MECONIUM. 91 

produced. The warm bath will, in general, promote the opera- 
tion of the purge, and exert a favorable influence on the general 
system, by its tendency to keep up a regular action of the cutane- 
ous exhalents. The extraordinary torpor of the intestinal canal, 
which sometimes occurs immediately after birth, depends, proba- 
bly, in most instances, on cerebral congestion; for I have frequently 
noticed that those infants who are born with a turgid and livid 
appearance of the face, and other manifestations of preternatural 
fullness of the vessels of the head, are much more apt to resist the 
purgative powers of the colostrum, and to require artificial purga- 
tions for the removal of the meconial matter, than such as are 
free from symptoms of cerebral congestion. Immersing the legs 
and lower portions of the abdomen in a bath, raised to as high a 
temperature as the infant can bear, without pain, at the same time 
that a piece of flannel wet with cold water is applied to the top of 
the head, frequently has an obvious effect in facilitating the ope- 
ration of the purgatives that may be given in such cases. An in- 
stance which quite recently came under my notice has convinced 
me, that much advantage may sometimes be derived from this 
mode of management, where there is difficulty encountered from 
intestinal torpor in procuring the evacuations of the meconium. 
The infant had taken three teaspoonfuls of castor oil with ten 
grains of rhubarb in conjunction with the repeated use of injec- 
tions without the desired effect. Thirty hours after birth no al- 
vine evacuation had taken place. The little patient lay in a state" 
of partial stupor; its abdomen was distended and evidently very 
sore to pressure. In this state the lower parts of its body were 
placed in warm water, while cold applications were made to the 
head. In less than five minutes after these measures were resorted 
to the bowels began to act, and four or five copious evacuations 
ensued in the course of three or four hours. 



92 ON THE TONGUE-TIE. 



CHAPTER III. 

ON THE TONGUE-TIE. 

It frequently happens that the tongue of infants is so tied down, 
and restrained in its actions by a preternatural conformation of its 
frsenum, that sucking is rendered extremely difficult, and, if it 
be not remedied, the power of articulating words, at a more ad- 
vanced age greatly embarrassed. 

In the majority of instances, the part which ties down the tongue 
consists of a thin transparent membrane, extending from the fleshy 
part of the frasnum to near the extremity of the tongue. Dr. 
Dewees considers this transparent, membranous production as an 
adventitious formation, wholly distinct from the proper substance 
of the fraenum. It appears to me, however, to be a mere mem- 
branous prolongation of, and perfectly continuous with the struc- 
ture of the frasnum. In some instances, instead of this membra- 
nous prolongation, the thick and fleshy fraenum itself is extended 
forwards in the same way, so as to confine the tongue and embar- 
rass its actions. When the tongue is in this condition, the infant 
is incapable of elevating it, or protruding it beyond the lips; 
sucking is performed with great difficulty, and attended with a 
peculiar "clucking" noise in the fauces. When the infant at- 
tempts to suck, the nipple is constantly slipping from its lips, 
from an inability to grasp it firmly with the tongue. It alternately 
seizes the nipple, and after a few imperfect efforts, lets it slip 
again, until it becomes fatigued and irritated with its fruitless ex- 
ertions, and begins to fret and cry. 

When the portion of the frasnum which restrains the actions of 
the tongue in this manner, is membranous, it ought, of course, to be 
immediately divided. According to my own experience, a pair 
of small blunt-pointed scissors is the most convenient and safe in- 
strument for dividing this membrane. Dr. Dewees, however, 
prefers a gum lancet for this purpose. The child must be taken 



ON THE TONGUE-TIE. 93 

into a good light, and laid across the nurse's lap with its face up- 
wards. In this position the operator should insinuate the extremi- 
ty of the forefinger of the left hand, between the side of the 
tongue and the corresponding portion of gums, and push the tongue 
upwards, whilst with the thumb of the same hand the lower jaw 
is depressed. The frasnum may thus, in general be exposed to 
view, and the stretched membrane divided by one stroke of the 
scissors or gum lancet. Crying often facilitates the operation con- 
siderably, by exposing the membrane freely and putting it on the 
stretch. There is seldom more than a few drops of blood discharged 
from the divided membrane. By carelessness and with improper in- 
struments, however, very serious mischief has been done, even in 
cases of this kind. About twenty years ago I witnessed an in- 
stance, where a young physician, in endeavoring to divide the 
membranous portion of the fraenum, with a pair of sharp-pointed 
scissors, pierced a blood vessel under the tongue, which occasioned 
an extremely alarming haemorrage. Just as he was about clip- 
ping the membrane, the infant suddenly threw its head upwards, 
and plunged the points of the scissors in, under the tongue. Sharp- 
pointed instruments ought never to be used for this purpose. No 
one can be entirely secure against accidents of this kind, in the 
sudden and active struggles which infants are apt to make during 
the operation. 

When the tongue is tied down, by the proper, fleshy fraenum 
extending too near its extremity, nothing can, with propriety, be 
done towards remedying the evil. Dr. Dewees, has "never ven- 
tured to do any thing in cases of this kind." This variety of the 
tongue-tie is indeed very rarely so great, as to give rise to any 
serious difficulty of sucking; and the advantages to be gained from 
a division of the fraenum, are by no means adequate to justify an 
operation attended with so much risk of alarming consequences. 
Very alarming and even fatal haemorrage has been the result of 
this operation, and authors mention convulsions and "swallowing 
of the tongue," as occasional consequences. 



94 INFLAMMATION AND SWELLING OF THE BREASTS. 



CHAPTER IV. 

OF THE INFLAMMATION AND SWELLING OF THE BREASTS OF 
NEW-BORN INFANTS. 

New-born infants are liable to a singular inflammation and en- 
largement of the breasts, which though very rarely attended with 
any serious consequences when properly managed, has often been 
converted into a very painful and dangerous affection by the ig- 
norant and rude officiousness of nurses and others. The common 
opinion among mothers and nurses, is that these swellings arise 
from the accumulation of milk in the infant's breast, and, "that it 
must be squeezed or milked out, that they may be cured." Every 
effort is accordingly made, by squeezing, sucking, pressing, &c. to 
extract the supposed fluid, and as no milk can be obtained, the in- 
flammation which often follows this rude treatment, is usually as- 
cribed to the retention of the milk in the breast, and considered 
as a direct proof of the correctness of this opinion. I have met 
with several instances, in which this preposterous and highly inju- 
rious practice, brought on violent inflammation, which soon termi- 
nated in extensive suppuration of the breast, and in one case — a 
female infant, both breasts were entirely destroyed. 

These swellings come on immediately after birth; and it has 
been supposed, though I think erroneously, that they are generally 
formed before the infant is born. They are somewhat tense, 
elastic, and firm, and appear to consist of a moderate degree of 
inflammation of the cellular membrane with serous infiltration into 
this tissue. When the inflammation is aggravated, it extends itself 
to the mammas, and the skin becomes purplish over the central 
parts of the tumor. Occasionally, though, indeed, very rarely, 
the inflammation, even under a proper course of management, be- 
comes severe and continues for five or six days before it begins to 
subside. I have, however, never known a case of this kind to 






INFLAMMATION AND SWELLING OF THE BREASTS. 95 

terminate in suppuration and abscess, except where the inflamma- 
tion was aggravated by rough handling in the commencement. 

In moderate cases Dr. Dewees applies nothing more than "a 
piece of linen moistened with a little sweet oil;" and where the 
swelling and inflammation are considerable, he recommends the ap- 
plication of a bread-and-milk poultice, renewed every three or 
four hours. These are doubtless appropriate and useful remedies; 
but it has appeared to me, that in the ordinary cases of this affec- 
tion, a weak solution of the muriate of ammonia in vinegar and wa- 
ter — in the proportion of a drachm of the ammonia, to four ounces 
of water with the same quantity of common vinegar, acts much 
more promptly and certainly in reducing the swelling and inflam- 
mation, than either sweet oil or emolient poultices. The solution 
ought to be applied warm, by moistening pieces of linen with it, 
and laying them over the affected parts. I have seldom used any 
other application than this one, even where there was a considera- 
ble degree of inflammation. When the swelling and inflammation 
become severe, a few leeches, applied to the parts, succeeded by 
warm emolient poultices, will in general prevent the occurrence of 
suppuration. 



96 INFLAMMATION AND ULCERATION OF THE NAVEL. 



CHAPTER V. 



OF INFLAMMATION AND ULCERATION OF THE NAVEL. 

Inflammation and consequent ulceration about the navel is a 
frequent occurrence during the first nine or ten days after birth. 
This may arise from irritation occasioned by rude management 
in washing and dressing the navel, before the cord has been 
thrown off; or it may be the result of a slow and imperfect sepa- 
ration of the cord, in consequence of which it remains attached 
by a thin and firm filament and prevents the healing of the navel. 
Frequently, too, it arises from deficient attention to cleanliness, 
in the first washing of the infant; for if the white caseous matter, 
which is found deposited on its skin, be not carefully washed off 
from about the umbilicus, it soon acquires a very irritating char- 
acter, and gives rise to inflammation and excoriation of the navel. 
This, I am well satisfied is by far the most common source of this 
disagreeable affection of the navel. Children who are not pro- 
perly freed of this peculiar caseous deposition, where it occurs in 
abundance, almost invariably suffer more or less irritation and 
inflammation about the navel. Of the tendency of this white 
matter, to inflame and excoriate, the skin, when not properly 
removed, we often have abundant evidence on various parts of the 
body — particularly in the folds of the skin about the neck, joints, 
nates and groins. 

When the navel becomes irritated and inflamed, it soon acquires 
a deep red, excoriated and fungoid condition, discharging a thin, 
offensive and purulent matter, and evidently causes much suffer- 
ing and uneasiness to the infant. In some instances, the navel 
presents an elevated ulcerous surface, with an inflamed condition 
of the surrounding skin, and a copious discharge of thin irritating 
matter; in other cases, the central part of the navel shoots up a 



INFLAMMATION AND ULCERATION OF THE NAVEL. 97 

kind of fungous excrescence, of a dark-red and excoriated appear- 
ance, with but little surrounding inflammation or actual ulcera- 
tion. This fungoid tumor sometimes assumes a button-like form, 
with a narrow base, and a round expanded head like a cherry; 
in other cases, the tumor is broad at the base, tapering towards 
the top, or exhibiting nearly a cylindric form. 

When the navel becomes excoriated or ulcerous and discharges 
matter, while the cord remains attached by a filament, the simple 
division of this slight connexion will often suffice to arrest the pro- 
gress of the ulceration, and dispose the navel to cicatrize. When- 
ever the cord is so far separated as to retain only a simple fila- 
mentous connection with the umbilicus, the separation ought to be 
completed by clipping the filament with a pair of scissors, whe- 
ther there be inflammation and ulceration or not; for if this partial 
connection is suffered to continue after the usual period of separa- 
tion, it, of course, prevents the healing, and almost invariably 
causes severe inflammation and ulceration of the navel. 

When the fungoid little tumor in the bottom of the umbilical 
cavity has a narrow base, it may, in general, be speedily removed 
by passing a ligature round the pedicle, and drawing it sufficiently 
tight to arrest the circulation, without cutting into its substance. 
A strong silk thread will answer very well for this purpose. In 
the course of a few days, the tumor, usually, drops off, after which 
the part should be dressed with saturnine ointment, spread upon 
lint. Should the fungus, however, shoot up again, it must be 
repressed by astringent applications, or destroyed with one of the 
milder escarotic remedies. I have found the root of the sanguin- 
aria canadensis very finely powdered, an excellent escarotic in 
cases of this kind. A small portion of the powder should be put 
on the fungus, once or twice daily, and covered with lint spread 
over with a little lead ointment. When the surface and margin 
of the umbilical cavity are excoriated, and the discharge of mat- 
ter is copious, advantage may be obtained from the occasional 
application of a solution of sugar of lead, or what is better, a 
weak decoction of oak bark. 

In cases where the tumor is broad at the base, and where, of 
course, ligatures are inapplicable, recourse must be had to suita- 
ble astringents and escarotics. Dr. Dewees recommends "a 

O 



98 INFLAMMATION AND ULCERATION OF THE NAVEL, 

pretty strong solution of the nitrate of silver," applied by means 
of a camel hair pencil, « and repeated until the part heals." The 
nitrate of silver is an excellent escarotic where the surface of the 
tumor is ulcerated or raw and spongy. In some instances, how- 
ever, these excrescences are of rather a firm texture, and covered 
with a fine membrane — and in such cases, this escarotic is always 
extremely slow in destroying the tumor. I have occasionally 
used a strong solution of the sulphate of copper, with a satisfac- 
tory result in instances of this kind. One drachm of the sulphate 
should be dissolved in an ounce of water, and applied twice daily 
by means of a camel-hair pencil or a dossil of lint. We may 
frequently reduce these tumors without any escarotic applications, 
by means of strong astringents constantly applied, as is often done 
with hasmorrhoidal excrescences. Very finely pulverized oak 
bark, or Aleppo galls, sprinkled on the tumors, will sometimes 
cause them to shrink, at the same time that it tends to subdue the 
surrounding inflammation and to arrest the purulent discharge 
from the umbilical cavity. In the last case of this kind which 
occurred to me, I directed the nurse to drop a pinch of oak-bark 
powder, upon the excrescence thrice daily, and to wash the parts 
carefully with lukwarm water, every morning and evening; and 
the result was perfectly satisfactory. 

When the navel presents an elevated, ulcerous surface, we 
may often do much good by touching the ulcerated part very 
lightly with lunar caustic, and applying saturnine ointment, 
spread on lint, over it. If there is much inflammation of the navel 
and adjacent parts, a soft poultice made with lead-water and 
crumbs of bread, forms an excellent application. A solution of 
the sulphate of copper, in the proportion of ten grains to an ounce 
of water, may be applied with much advantage, when there is 
superficial ulceration, without much inflammation. It should be 
applied once or twice daily, and the part afterwards covered with 
lead ointment. Sprinkling the ulcerated surface with white 
lead, or with powdered oak bark or galls, will, in slight cases, 
frequently restore the parts to a healthy condition, without any 
other applications. I have seen prompt and very decided benefit 
derived, in a very aggravated case of ulcerated navel, from wash- 
ing the part, twice daily, with a decoction of the wild indigo 



INFLAMMATION AND ULCERATION OF THE NAVEL. 99 

root, (baptisia tinctoria). The best mode of applying this article, 
however, is in the form of a liniment, made by slowly simmering 
the coarsely powdered root in cream, and afterwards squeezing 
it through a thick piece of linen or flannel. This should be ap- 
plied with a soft pencil or feather, three or four times daily; or a 
piece of lint may be moistened with it, and laid over the ulcerated 
surface. I have repeatedly applied this liniment, to excoriated 
and ulcerated nipples, and generally with great advantage. 

Cleanliness is an important observance in cases of this kind. 
Whatever applications may be made, the parts should be care- 
fully washed with lukewarm water, at least twice daily, and where 
the discharge is particularly offensive, or copious, the parts imme- 
diately surrounding the umbilical cavity should be washed or 
carefully wiped clean, with a soft piece of linen wrung out of 
warm water, repeatedly during the day. 



CHAPTER VL 



OF THE JAUNDICE OF INFANTS. 



Newly-born infants are liable to an icteric state of the skin 
which though generally of a very slight and transient character, 
requiring little or no attention, sometimes assumes a degree of 
violence and obstinacy which calls for prompt and active reme- 
dial measures. 

In a great majority of infants, this yellowness of the skin comes 
on within three or four days after birth, unattended by any mani- 
festations of indisposition; and after having remained stationary, 
for a few days, gradually disappears, without any unpleasant con- 
sequences. This peculiar discoloration of the skin is, generally, 
regarded as wholly distinct from jaundice, and altogether inde- 
pendent of hepatic derangement, or deposition of bilious matter 
under the cuticle. "It is difficult," observes Dr. Dewces, "to 



100 JAUNDICE OF INFANTS. 

say, to what this yellow tinge may be owing; certain it is, it can- 
not be attributed to the presence of bile, since neither the urine 
nor the white of the eyes assume the yellow hue." It may be 
doubted, however, whether either of these facts can with propri- 
ety be regarded, as " certain" evidence, that the yellowness in 
question, is independent of bilious matter, since a temporary secre- 
tion of the carbonaceous matter which during fcetal life is secre- 
ted by the liver, may it is presumed, take place into the rete-mu- 
cosum without showing itself either in the urine or in the eyes. 
Nor does the assertion, that the urine is always free of bilious 
matter accord with my own observations; for since my attention 
has been particularly directed to this subject, I have not met with 
one instance, where the urine did not acquire a slight bilious hue, 
about the time the yellowness of the skin was going off, although 
previously of a perfectly natural color. The liver appears to be 
the principal depurating organ, during the uterine stage of life. 
As soon as the infant is born, however, a large share of this office 
is transferred to the lungs and the skin. The skin at the same 
time, suddenly becomes highly engorged with blood, as is mani- 
fested by the redness and fulness which usually occurs a short time 
after birth. — It becomes the principal seat of sensibility and sen- 
sation, and its transpiratory function, is for the first few days, per- 
formed in a feeble and imperfect manner. It seems probable, 
therefore, that whilst these changes in the excretory functions are 
going on, the blood may become slightly charged with recremen- 
titious matter of a bilious or carbonaceous character, and that 
in the irritable and congested condition of the skin to which we 
have just referred, a portion of this matter may be deposited 
on the rete-mucosum or cutis, without any actual morbid derange- 
ments either of the liver, or of the general system. 

When the infant does not become restless and fretful and takes 
its nourishment freely, and the alvine discharges are manifestly 
colored with bile, this yellowness of the skin requires no particular 
attention, as it will pass off spontaneously, in the course, generally, 
of three or four days, without any unfavorable effects, either imme- 
diate or remote. But when the white of the eyes becomes yellow, 
the urine charged with bilious matter, the bowels costive, and the 
stools whitish or clay-colored, accompanied with an inclination to 



JAUNDICE OF INFANTS. 10] 

vomit, or with actual vomiting, and an anxious and distressed ex- 
pression of the countenance, the disease is evidently connected 
with more or less serious disorder of the biliary organs, and should 
be promptly opposed by a suitable course of remedial measures. 
When along with these symptoms, there is fever, and a swollen 
and tender state of the right hypochondriac and epigastric regions, 
the worst consequences are to be apprehended ; for cases of this 
kind, frequently resist every curative effort that can be made, and 
proceed with increasing violence to a speedy termination in death, 
or assume a chronic character, with progressive emaciation of the 
extremities, and tumefaction and hardness of the abdomen, until 
the vital powers are consumed. Fortunately, however, these dan- 
gerous cases are not common. In by far the greater number of 
instances, the disease is not attended with any violent and dis- 
organizing form of hepatic disorder, and, though manifestly de- 
pendent on biliary derangement, is of a comparatively mild and 
manageable character. 

The exciting causes of infantile jaundice are, doubtless, very 
various, Mr. Baumes thinks that meconial matter unduely re- 
tained in the bowels, is frequently concerned in the production of 
the disease; and Mr. Gardien expresses the same opinion. Dr. 
Underwood does not believe that the meconium can have any 
part in producing jaundice, except, perhaps, by obstructing the 
orifice of the biliary duct, for which it seems to be well adapted 
by its peculiarly viscid and adhesive consistence. I am inclined 
to think, however, that this writer has not attached sufficient im- 
portance to this recrementitious substance as a source of jaundice 
in newly-born infants. To whatever circumstance it may be as- 
cribed, I am persuaded that this disease occurs more frequently 
where there is delay and difficulty experienced in purging off the 
meconium, than where this substance is easily and entirely evacu- 
ated during the first twenty-four hours. It is, indeed, not probable 
that the yellow color of the skin is, in any degree, derived from 
absorbed meconial matter; and it may well be questioned whether 
any portion of this recrement is ever absorbed into the circulation. 
The way, perhaps, in which retained meconial matter contributes 
to the production of infantile jaundice is, by exciting irritation in 
the intestines, and, in conjunction with other causes, particularly 



102 JAUNDICE OF INFANTS, 

the purgatives that may be employed for the removal of this sub- 
stance, giving rise to mucous inflammation of the duodenum and 
consequent functional derangement of the liver, or obstruction to 
the flow of bile into the bowels. That a morbidly irritable or 
inflamed condition of the mucous membrane of the duodenum, is 
apt to give rise to jaundice is well known. "A curious patholo- 
gical fact," says Dr. Johnson, "has lately been fairly established — 
namely, that irritation or inflammation of the mucous membrane 
of the duodenum, will sometimes produce jaundice, where no ob- 
struction can be detected in the biliary ducts." Cases of this 
kind are always attended with excruciating paroxysms of pain in 
the region of the duodenum, an hour or two after taking nourish- 
ment, resembling the pain produced by the passage of a biliary 
concretion through the common bile duct. I have met with 
several cases of this variety of the disease, in adults, which, after 
all the usual remedies for jaundice had been ineffectually tried, 
were speedily cured, and without a single recurrence of the pains 
by an exclusive liquid mucilaginous diet, and the application of 
a blister to the epigastrium. It is highly probable, that the jaun- 
diced appearance which occurs in yellow fever, depends, mainly, 
on the gastro-duodenal inflammation so universally connected with 
that disease. In relation to infantile jaundice, my own observations 
have satisfied me, that, in some instances at least, this disease is 
the immediate result of mucous inflammation of the upper portion 
of the intestinal canal. In a dissection which I made about two 
years ago, of an infant that had died in a state of deep jaundice, 
apparently in consequence of inflammation of the liver, I found 
the mucous membrane of the duodenum in a highly diseased con- 
dition. Some parts of it were of a uniform scarlet color, — others 
were softened to the consistence of jelly, and of a gray or ashy hue, 
and in several places it was entirely destroyed and removed, 
leaving the muscular tunic bare. The orifice of the bile duct 
was slightly tumified, but the duct was pervious throughout. 
The liver was much engorged with blood, but exhibited no other 
obvious marks of structural lesion. Improper artificial nourish- 
ment during the first two or three days afterbirth, and the exhi- 
bition of irritating purgatives for the removal of the meconium, 
are doubtless frequently concerned in the production of this dis- 



JAUNDICE OF INFANTS. 103 

ease. The gastroduodenal irritation which is apt to be excited 
in this way, can seldom fail to produce more or less functional de- 
rangement of the liver; and when the duodenal irritation pas- 
ses into a state of actual inflammation, jaundice may result, 
either from spasmodic closure of the mouth of the common bile 
duct, in consequence of the extremely irritable condition of the 
duodenum, or from sympathetic irritation with excessive sanguin- 
eous engorgement of the liver, and consequent functional torpor. 
In cases attended with a highly irritated or sub-inflamed condition 
of the duodenum, there is usually much sickness and frequent 
vomiting of a glairy fluid; the epigastrium is tender to pressure, 
and the little patient is affected with occasional paroxysms of 
violent screaming and agitation, particularly some time after tak- 
ing nourishment. 

In some instances the disease is unequivocally attended with in- 
flammation of the liver. The right hypochondrium becomes tu- 
mid, tense, and tender to the touch. The fever is strong, the 
respiration short and oppressed, and almost every attempt to move 
or lift the infant, immediately increases its sufferings and causes it 
to scream out with anguish. 

Very frequently, however, the hepatic derangement upon 
which the jaundice depends is entirely unconnected with inflam- 
mation. The liver may be in a state of inactivity from excessive 
sanguineous engorgement: or its torpor may depend on induration 
with or without enlargement, or on some other form of structional 
disorder. In cases of this kind there is, in general, but little or 
no febrile irritation. The infant is apt to fall into a drowsy and 
languid condition, with weakness of the digestive functions, 
acidity, vomiting, and flatulent colic pains. The disease usually 
assumes a chronic character, attended with progressive emaciation, 
and derangement of the alimentary canal. Instances depending 
on excessive sanguineous congestion of the liver, are usually at- 
tended with manifest indications of a general plethoric condition 
of the system. It has appeared to me that jaundice, from this 
cause, is most apt to occur in those infants, who are born with a 
turgid and livid appearance of the face and body, and an oppressed 
state of the brain — more especially where the vessels are not 
promptly relieved by abstracting blood from the divided cord. 



104 JAUNDICE OF INFANTS. 

Without doubt, too, infantile jaundice, may in some instances 
depend on obstruction to the regular flow of the bile, from spas- 
modic constriction of the biliary canals, wholly independent of any 
local or general inflammatory excitement. Mr. Gardien, ob- 
serves that spasmodic constriction of the biliary pores may be oc- 
casioned by, the sudden exposure of the newly-born infant to cold 
air or water — the constringing impressions of which, may be sym- 
pathetically conveyed from the skin to the hepatic system. When 
we advert to the intimate relation which subsists between these two 
organs, and the extremely sensible and excitable state of the skin, 
immediately after birth, we can scarcely doubt that the disease 
may, be produced in this way. 

Treatment. — It has already been stated that in the ordinary 
cases of yellow ess of the skin — when the infant does not manifest 
any obvious indications of indisposition, and the alvine discharges 
continue to be colored with bile, no active treatment is required. 
The customary warm bathing for preserving a pure and healthful 
condition of the skin, and a proper attention to the state of the 
infant's bowels — promoting their action, when they are torpid, and 
restraining it when there is a tendency to griping and diarrhoea, 
is in general all that is required in cases of this simple character. 

When the disease is not attended with an inflamed condition of 
the liver, though obviously connected with derangement of the 
biliary organs — that is, when the skin and eyes are yellow, the 
urine bilious, and the stools whitish or clay-colored, without any 
soreness or tenderness to pressure in the right hypochondriac and 
epigastric regions, much benefit may sometimes be derived from 
emetics. In cases of mere congestion and inactivity of the liver, 
or in hepatic torpor from any cause, the concussive operation of an 
emetic frequently proves highly beneficial by accelerating the cir- 
culation in the portal system, exciting the action of the liver, and 
relieving its congested condition, by determining the blood from 
the internal to the external parts of the body. A few grains 
of ipecacuanna should be given every fifteen or twenty minutes 
until vomiting is produced; and when the disease is obstinate, 
the emetic may be advantageously repeated, every other day, until 
the alvine evacuations acquire a bilious appearance. In all in- 



JAUNDICE OF INFANTS. 105 

stances, however, of a manifestly inflammatory character, attended 
with fulness, tension and unequivocal soreness of the region of the 
liver and stomach, emetics cannot be employed without consider- 
able risk of injurious consequences. The bowels ought to be 
freely evacuated in the commencement of the treatment; and for 
this purpose calomel and castor oil appear to be the most suitable 
means. A fourth of a grain of calomel should be given every 
two hours, until two or three grains have been taken. If free 
purging does not ensue, the operation of the calomel must be pro- 
moted by castor oil, given in teaspoonful doses every hour, until 
the desired effect is obtained. After the bowels have been once 
freely evacuated, they must be kept in a loose state, by adminis- 
tering a fourth of a grain of calomel every morning noon and 
evening, with an occasional teaspoonful of castor oil, should the 
torpor of the intestines render an additional purgative necessary. 
Calomel is a valuable medicine in every modification of infantile 
jaundice, on account, both of its aperient effects on the bowels, 
and its specific operation on the biliary organs, and general capil- 
lary system. In conjunction with these remedies, the daily use 
of the warm bath, is often decidedly beneficial; and when the in- 
fant can bear it without manifest suffering, gentle frictions with 
the bare hand, over the region of the liver and stomach, repeated 
several times daily, frequently produces an obviously salutary 
effect in cases of this kind. It need scarcely be observed, that 
frictions of the abdomen would hardly fail to prove injurious in 
cases attended with hepatic inflammation or abdominal tender- 
ness. It is only when the region of the liver and stomach may 
be pressed without causing the infant to cry or manifest increased 
distress and sufferings that frictions can be used with propriety — 
and when this is the case, they almost always prove decidedly 
beneficial. 

When infantile jaundice is attended with a febrile condition, 
and symptoms indicative of hepatic inflammation — such as fulness, 
and tenderness in the region of the liver — a very scanty secretion 
of high-colored urine, absence of the respiratory motions of the 
abdominal muscles, frequent nausea and vomiting, and an expres- 
sion of pain and suffering in the countenance, a treatment more 
decidedly antiphlogistic is required. Four or five leeches, if they 

P 



108 JAUNDICE OF INFANTS. 

can be procured, ought to be applied to the right hypochondrium. 
The local abstraction of blood, by leeches, in cases of this kind, 
is of the utmost importance, and ought never to be omitted, where 
it is practicable. In violent cases, the application of a small blis- 
ter to the region of the liver, will often procure very considerable 
relief. No injurious consequences need be apprehended from 
a vesicatory, at this early stage of life, if managed with 
proper care. I have in several instances, where the liver ap- 
peared to be in a state of inflammation, resorted to the applica- 
tion of a blister, with unequivocal advantage. The plaster should 
not be suffered to remain on the skin longer than about two hours. 
The skin generally becomes slightly inflamed by this time; and 
if the plaster be now removed, and a soft warm poultice laid over 
the part, a fine blister will be raised, without harassing the in- 
fant. The bowels must be freely evacuated with calomel, aided 
by castor oil. A half a grain of calomel should be given every 
two hours, until two or three grains are taken, and followed by a 
teaspoonful of castor oil, every two hours until active purging is 
produced. When the stomach is very irritable, however, and 
there is reason to apprehend the existence of a highly irri- 
tated or subinflammatory condition of the mucous membrane of 
the stomach and superior portions of the intestinal tube — that is, 
where there is frequent vomiting of a glairy fluid, with occasional 
fits of agitated screaming and manifest distress soon after taking 
nourishment into the stomach, together with tenderness and ten- 
sion of the epigastrium, it will be better to employ minute doses 
of calomel and ipecacuanna without the castor oil, and pro- 
mote their action on the bowels by laxative clysters. I have in 
a few cases employed these two articles, according to the formula 
given below,* with a very satisfactory result. A dose should be 
given every two hours, in conjunction with the administration of 
laxative enemata, until adequate evacuations have been procured. 
The same powders, or minute portions of calomel without the 
ipecacuanna, must afterwards be regularly given every morning, 
noon, and evening, until the alvine discharges become conspicu- 

* R. Subwiriat. Hydrarg. gr. iii : Pulv. Ipecac, gr. ii ; Sachcr. Alb. gr. xii. 
Mix and divide the whole into 12 equal parts. 



JAUNDICE OF INFANTS. 107 

ously bilious. No ill effects need be feared from ipecacuanna in 
this irritable and irritated state of the primss vise. When exhib- 
ited in very small doses, so far from exciting or irritating the 
stomach, it generally exerts a decidedly calming and anti-emetic 
influence, and almost always promotes, to an evident degree, the 
aperient operation of the calomel. In cases of this inflammatory 
character, some advantage may be derived from the application 
of a large warm emolient poultice over the upper part of the ab- 
domen, and frequently renewed so as to keep it warm. In some 
instances the calomel fails to excite the action of the liver, and 
causes injurious irritation of the mucous membrane of the bowels, 
giving rise to frequent small turbid watery discharges, attended 
with severe griping and increased abdominal tenderness. When this 
occurs, we may sometimes obtain the desired mercurial influence 
on the liver, by applying a mercurial plaster over the region of this 
organ, or by the internal use of a quarter of a grain of Dover's 
powder in union with half a grain of finely powdered dry and 
hard mercurial mass, exhibited every morning, noon and evening. 
A fourth of a grain of Dover's powder, in conjunction with a 
grain of the bi-carbonate of soda, given every three or four hours, 
is an excellent remedy for allaying the intestinal irritation and 
exhausting diarrhoea which sometimes occurs in the advanced 
stages of the disease. 

In general calomel and purgatives are the means upon which 
our main reliance should be placed in treatment of this malady. 
The bowels are usually very torpid, and considerable difficulty is 
often experienced in procuring the necessary evacuations. It is 
seldom, however, that any more active purgatives are required 
than the articles already mentioned, in conjunction with laxative 
enemata. Should this necessity occur, we may safely, and with 
almost certain success add from eight to ten drops of spirits of 
turpentine to the dose of castor oil. I have resorted to this mix- 
ture, in cases of this kind, with the happiest effect. 

The vegetable alkalies have a very beneficial tendency in cer- 
tain modifications of this disease. The bi-carbonate of soda, is 
especially useful in cases of a chronic character, unattended by 
symptoms of active abdominal inflammation. A grain of this al- 
kali, dissolved in a teaspoonful of carbonated water, or a teaspoon* 



108 JAUNDICE OF INFANTS. 

fill of the common soda mineral water, (of the strength of sixty 
grains of soda to ten ounces of carbonated water,) given at inter- 
vals of two or three hours, is well adapted to do good, where there 
is a deficiency of bile in the bowels, by its direct tendency to pre- 
vent fermentation and the consequent generation of acid and 
other irritating substances in the primae viae, and by promoting the 
regular peristaltic action of the bowels. After the alvine dis- 
charges have become bilious, the regular exhibition of both the 
soda and calomel should be discontinued, and the bowels kept in 
a loose state by small doses of castor oil, or the occasional admin- 
istration of an injection. In chronic cases of infantile jaundice, 
considerable advantage may, sometimes, be gained, from the use 
of the extract of dandelion, in union with bi -carbon ate of soda. 
Ten grains of the extract, dissolved in about a teaspoonful of 
warm water, together with two grains of the soda, may be given 
three times daily. It generally keeps up a regular action of the 
bowels — excites the urinary secretion, and appears to produce a 
salutary effect upon the biliary organs, and general capillary sys- 
tem, as may be inferred, from the gradual subsidence of the ab- 
dominal fulness and tension, and the disappearance of the yellow- 
ness of the skin, under its use. In a case which 1 attended a few 
months ago, the disease gradually increased in violence under the 
use of small doses of calomel, and ipecacuanna. The abdomen 
became distended and hard, and the skin of a deep yellow color. 
The calomel was finally omitted, and ten grains of the dandelion 
with two grains of soda administered three times daily. In a few 
days after the use of this remedy was commenced, the disease 
began to abate, and gradually disappeared altogether. 

In cases attended with severe flatulent and spasmodic pains of 
the stomach and bowels, three or four grains of assafoetida, dis- 
solved in a few tablespoonsful of warm water, and injected into 
the rectum, will generally afford much relief. We may also ad- 
minister two or three drops of sulphuric aether in a teaspoonful of 
hop tea, with decided benefit in such cases. The infusion of hops 
is, indeed, a most excellent palliative in the jaundice of infants. 
It does not interfere with the action of the necessary laxatives, 
and along with its anodyne effects, generally exerts a decidedly 
favorable influence on the digestive functions. When the disease 



OF THE RETENTION AND SUPPRESSION OF URINE. 109 

depends on engorgement and torpor of the liver, without structural 
lesion, Gardien recommends the use of the black oxide of iron, 
with the yolk of an egg. Two or three grains of the former, 
beat up with a yolk of an egg, given three times daily, is said 
to produce excellent effects, in some instances of this kind. 



CHAPTER VII. 



OF THE RETENTION AND SUPPRESSION OF URINE. 

Some urine is probably, in most instances, secreted, and de- 
posited in the bladder, before the infant leaves the womb; for, in 
the majority of cases, a discharge of urine occurs, within a very 
short time after birth. Sometimes, however, the kidneys appear 
to remain inactive, and little or no urine is evacuated for many 
hours after the birth of the infant. I have met with several in- 
stances where a period of upwards of twenty hours elapsed before 
a sufficient quantity of urine was secreted and collected in the 
bladder to excite an evacuation. It is of great consequence, in 
cases of this kind, to acertain whether the non-occurrence of the 
urinary discharges, depends on a suppression of the secretion from 
torpor or inactivity of the kidneys, or whether the urine though 
adequately secreted, is retained in the bladder in consequence of 
some obstruction to its discharge, or deficient contractile power 
of the bladder. When there is but little or no urine secreted 
during the first fifteen or twenty hours after birth, the infant 
seldom manifests any uneasiness that can be referred to this 
cause; but when the renal inactivity is protracted much beyond 
this period, the consequences may be very serious and even fatal. 
Cases of this kind are, indeed, extremely uncommon. I have 
seen but one instance of very protracted ischuria renalis,in a newly- 
born infant. The child was born about 10 o'clock in the evening. 
On the following morning I was informed that it had as yet voided 



110 OF THE RETENTION AND SUPPRESSION OF URINE. 

no urine. It appeared to be quite healthy, and free from uneasiness. 
I ordered a teaspoonful of weak parsly-tea, with two drops 
of sweet spirits of nitre every twenty minutes. In the evening, I 
found the child in a drowsy state, and restless. I assured myself 
that the bladder was empty, by the introduction of a very small 
catheter, The warm bath was ordered, and frictions over the 
abdomen and loins, with a mixture of juniper-oil, and tincture of 
squills. Internally three drops of sweet spirits of nitre, together 
with four drops of the vinegar of squills were given, every half 
hour in a teaspoonful of wild carrot-seed tea. Next morning the 
little patient was in a state of complete stupor — the respiration 
slow, weak and irregular, and the eyes insensible to light. On 
the following night it died. I was not permitted to make a post- 
mortem examination. In general, the action of the kidneys is 
readily excited, where the urinary secretion is slow, or suppressed, 
during the first nine or ten hours after birth. A few teaspoon- 
fuls of parsly or wild carrot-seed tea, with two or three drops 
of sweet spirits of nitre, given every half hour, and the warm hip 
bath, (after the bowels have been freely evacuated,) are generally 
sufficient to excite the secretory action of the kidneys. Should 
these means fail to produce the desired effect, recourse may be 
had to friction over the loins and hypogastric region, with warm 
vinegar of squills, or a mixture of about a drachm of juniper oil 
with an ounce of sweet oil, or with the expressed juice of onions 
diluted with water; and internally, to the exhibition of a few 
drops of the vinegar of squills, a drop of spirits of turpentine in a 
teaspoonful of milk or four or five drops of the expressed juice of 
roasted onions, every thirty or forty minutes; in conjunction with 
warm bathing, laxatives, and if necessary laxative enemata. 

When there is retention of the urine — that is when the urine is 
regularly secreted, and conveyed into the bladder, but cannot be 
discharged in consequence of a spasmodic constriction or mechani- 
cal obstruction of the urethra, or perhaps, deficient contractile 
power of the muscular coat of the bladder, the phenomena, con- 
sequences and appropriate mode of management are very different 
from those which belong to suppression of the urinary secretion. 
Instances of more or less complete retention of the urine, immedi- 
ately after birth are by no means uncommon. Obstruction of 



OF THE RETENTION AND SUPPRESSION OF URINE. HI 

the urethra or of the neck of the bladder by viscid and inspissated 
mucus, is probably the most frequent cause of retention of the 
urine in newly-born infants. When by the gradual accumulation 
of the urine, the bladder becomes considerably distended, the in- 
fant begins to manifest pain and distress, which is obviously in- 
creased by pressure made with the hand upon the hypogastric 
region. The distended bladder may be more or less distinctly 
felt above the pubis; the infant is restless, its countenance has an 
expression of sutTering and distress, and its legs are constantly 
drawn up, to relieve the pressure of the abdominal muscles. If 
the obstruction be not removed, the abdomen gradually becomes 
more and more enlarged by the distended bladder, and acquires, 
at last, a tense and shining appearance, with the superficial veins, 
very much enlarged and turgid with blood. If relief be not 
obtained, rupture of the bladder finally takes place, and death is 
the inevitable consequence. The bladder sometimes becomes 
enormously distended before ulceration or rupture takes place. 
Dr. Dewees gives an account of a very remarkable instance of 
this kind, in which Dr. Parrish drew at one time eighteen ounces 
of urine from the bladder. The child did not recover. A few 
years ago I was called to consult in a case of this kind. The 
attending physician was a very young man, and tampered with 
inefficient means until it was too late. Before I arrived the blad- 
der had yielded to the distending force, and the urine was extra- 
vasated into the cavity of the peritoneum. Of this I satisfied my- 
self by a post-mortem examination. 

In some cases, after the bladder has become much distended, 
small portions of urine are, from time to time evacuated, although 
the quantity retained, is progressively increased; and this occur- 
rence almost always misleads the nurse, and often even the medi- 
cal attendant, and removes every suspicion of urinary difficulty. 
The urine is thus gradually accumulated, and the manifest dis- 
tress and suffering is ascribed to other causes, until the bladder, 
at last, gives way, and the infant dies in great agony from peri- 
toneal inflammation. I am persuaded that infants sometimes die 
in this way, who might easily be saved if the real cause of its suf- 
ferings did not thus escape the attention of the practitioner. 
" We have strong reasons to believe," says Dr. Dewees, " that 



112 OF THE RETENTION AND SUPPRESSION OF URINE, 

many have died of suppression {retention) of urine,though we were 
assured they had passed water — the same was insisted on, for 
awhile in the case (referred to above) just mentioned, and perhaps 
there may have been a small discharge, as always happens when 
the bladder becomes excessively distended." When the infant 
becomes restless and fretful, and persists in keeping its legs 
drawn up, and particularly when we are informed that its abdo- 
men is swollen and hard, the region of the bladder should be 
carefully examined, and no reliance placed on the nurse's decla- 
ration, that the urine is regularly evacuated, if there is the slight- 
est reason on examination, to suspect an accumulation of urine 
in the bladder. 

The external urinary passage ought always to be carefully ex- 
amined in newly-born infants. I was once called into the coun- 
try, to visit an infant, which, I was told, had not discharged any 
urine since its birth. I saw it about forty hours after birth, and 
found it evidently in a state of very great suffering. The bladder 
was very much distended, and could be easily felt, beneath the 
abdominal muscles. On examining the urethra, for the purpose 
of introducing a small flexible bougie, I found its orifice closed, 
by a thin semi-transparent membrane, about the tenth of an inch 
below the surface, or extremity of the passage. I divided it with 
a sharp-pointed history, and the urine instantly gushed out with 
much force. Sometimes the prepuce is entirely closed. I have 
seen two cases of this kind. In one there was a very small 
opening, scarcely admitting a pin's head, and altogether in- 
sufficient to admit of the discharge of the urine; in the other case, 
the closure was complete. In both, the difficulty was speedily 
removed by circumcision. 

The common practice of exhibiting diuretics, or remedies cal- 
culated to increase the secretory action of the kidneys, in cases of 
retention of the urine, is always highly improper, as it cannot, in 
any way, aid in removing the obstruction, but must necessarily 
tend to aggravate the distress and danger, by rapidly increasing 
the fluid in the bladder. 

When the inability to discharge urine, depends on retentionoi 
the secretion in the bladder, and the vesical distention and sufferings 
of the little patient are, as yet, not so great as to require prompt 



OF THE RETENTION AND SUPPRESSION OF URINE. US 

relief, a trial may be made with the warm bath, purgatives, emo- 
lient enemata, and gentle frictions with camphorated oil, or tinc- 
ture of hyosyamus, over the pubic region. Where the obstruction 
is slight, these measures will sometimes, remove the difficulty and 
bring on the urinary discharge. They should not, however, be 
long persisted in, if they do not procure some advantage before 
the symptoms become more urgent. The bougie and catheter 
arc the proper means for giving relief; and the obstruction is but 
very rarely of such a character as to render the judicious employ- 
ment of them necessarily abortive. The introduction of a small 
bougie will, sometimes, remove the obstruction and procure re- 
lief. But when the retention arises from a spasmodic constriction 
of the urethra, or sphincters of the bladder, or when the bladder 
has lost its power of contraction from over distention, the bougie 
can do little or no good, and recourse must be had to a proper 
sized flexible catheter. Great care and delicacy must be prac- 
tised in the attempt to introduce such an instrument into the 
bladder of an infant. A very slight force will lacerate the urethra, 
and form an artificial passage into the cellular tissue of the per- 
ineum. I once knew a young surgeon, in attempting to introduce 
the catheter into the bladder of an infant, (male) push it through 
the membraneous portion of the urethra two or three inches be- 
fore he discovered that the instrument was not in the natural 
passage. The child died. When the bladder has been greatly 
distended, and relieved by the catheter,- its contractile power is 
apt to become temporarily impaired, so as to suffer the urine to 
re-accumulate to an extent suificient to keep the infant in a state 
of constant uneasiness or distress, although a regular and appar- 
ently sufficiently copious discharge from the bladder takes place. 
Hence in instances of retention, where there has been great dis- 
tention of the bladder, it often becomes necessary to use the 
catheter repeatedly, until the bladder regains sufficient power to 
evacuate itself, without artificial assistance. Sprinkling a little 
cold water on the lower part of the abdomen will sometimes 
excite the bladder into action in cases of this kind. The appli- 
cation of camphorated oil, by gentle friction over the pubic re- 
gion, may also aid in restoring a proper tone to the muscular coat 
of the bladder. 

Q 



114 OF THE RETENTION AND SUPPRESSION OF URINE. 

When there is reason to believe that the retention depends on 
spasmodic constriction of the urethra, a drop of the muriated 
tincture of iron, given every twenty or thirty minutes, may be 
beneficial. In spasmodic retention of urine in adults, this article, 
sometimes affords speedy relief; and it would doubtless exert a 
similar beneficial effect in retention of the same character in in- 
fants. In all cases particular attention ought to be paid to the 
state of the bowels. The meconial matter should be completely 
evacuated, if the urinary difficulty occurs during the first few 
days after birth — and in all instances the bowels ought to be 
freely evacuated. 



OF DYSURIA. H5 



CHAPTER VIII. 



OF DYSURIA— OR PAINFUL AND DIFFICULT MICTURITION. 

Pain and difficulty in voiding urine is a frequent complaint 
among infants. It is particularly apt to occur during dentition, 
and sometimes acquires a very distressing degree of violence. 
The child may, in other respects appear perfectly well and play- 
ful, but the moment it begins to discharge urine, it becomes agi- 
tated with excruciating pains, and shrieks uninterruptedly and 
violently until the evacuation is completed, when it instantly be- 
comes quiet and as well as usual. Not unfrequently this painful 
urinary affection goes on for many days, before its true character 
is detected — the vehement fits of screaming being usually as- 
cribed to griping or transient colic pains. When an infant is ob- 
served to have occasional fits of violent shrieking and agitation, 
without any obvious cause, painful micturition may be suspected: 
and on proper enquiry it will, probably, be found that these spells 
of suffering, occur only when the infant is voiding urine — a coin- 
cidence which will, at once render the nature of the evil manifest. 
In many instances, however, the pain is much less severe. Instead 
of the occasional fits of excruciating suffering, the child manifests 
a very frequent desire to pass urine, which is voided in very small 
quantities and always with obvious distress and uneasiness. This 
difficulty sometimes continues for many months — particularly if the 
child be cutting teeth, and may ultimately lead to very distressing 
consequences. 

These affections are almost always attended with an unnatural 
condition of the urinary secretion. In the majority of cases the 
urine contains a larg-e portion of lithic acid; and occasionally it 
is highly charged with phosphatic sedimentous matter. These 
substances impart a peculiarly irritating quality to the urine; 



116 OF DYSURIA. 

and when they are copious, and the system is in an irritable 
condition, as it usually is during dentition, they may readily pro- 
duce a considerable degree of irritation about the neck of the blad- 
der, and give rise to pain and difficulty in passing urine. Children 
who are much affected with acidity in the primae via?, arc most 
apt to experience urinary difficulties of this kind. The tendency 
of acid in the alimentary canal to increase the secretion of lithic 
acid by the kidneys is well known; and it is equally well ascer- 
tained that an excess of lithic matter in the urine, seldom fails to 
manifest itself by some irritation about the neck of the bladder, 
and more or less painful micturition. 

Dentition, and a disordered state of the digestive functions con- 
stitute the principal remote causes of this form of urinary disease. 
The former by the general irritative condition of the system 
which it causes, strongly favors the development of the lithic 
acid diathesis; and, as has already been stated, the generation 
of acid in the alimentary canal, in consequence of feeble digestive 
powers, or the use of improper articles of food, appears to furnish 
the elementary materials, for the formation of lithic deposits in 
the urine. Intestinal irritation from worms, appears in some in- 
stances to give rise to painful and difficult micturition — though 
in cases of this kind the urinary deposits are usually of the alka- 
line variety. Ascarides frequently occasion considerable irri- 
tation about the neck of the bladder, and become the source of 
urinary difficulties. 

Treatment. When a child becomes affected with pain and dif- 
ficulty in passing urine, this secretion ought to be carefully exam- 
ined, both in a recent state, and after it has stood for some time. 
If the sedimentous matter of the urine be of a red, or reddish 
color, remedies calculated to counteract the secretion of lithic 
acid by the kidneys will be indicated and will probably procure 
speedy relief. The proper treatment in such cases, consists in 
the employment of means suited to coirect the digestive and in- 
testinal functions, and to keep up a regular action of the cutane- 
ous emunctories. The bowels should be freely evacuated with 
magnesia and rhubarb, and afterwards kept in a moderately loose 
state by the daily use of small doses of calomel and ipecacuanna. 



OF DYSURIA. 117 

A grain of the former, with a fourth of a grain of the latter, con- 
stitutes a proper dose for a child under five years of age. Where 
there is a prevailing tendency to acidity in the primae viae, much 
benefit may be obtained from the use of the sub-carbonate of pot- 
ash, in union with a weak infusion of colomba. From two to 
three grains of the potash dissolved in a teaspoonful of weak in- 
fusion of colomba, diluted with a small portion of barley water, 
flaxseed tea, or some other mucilaginous fluid, may be given 
once, twice, or thrice daily, according to the urgency of the uri- 
nary affection. The diuretic and antilithic properties of the sub- 
carbonate of potash, renders it a peculiarly suitable medicine in 
cases of this kind. Small doses of magnesia, lime-water and milk, 
and the bi-carbonate of soda, also, frequentffprocure relief. When 
the general system is in a slightly febrile condition, as it often is 
during dentition, considerable advantage may be derived from te- 
pid bathing, in conjunction with mild diaphoretic remedies; such 
as the spirit, minderiri, with the addition of a small portion of 
sweet spirits of nitre, and syrup of squills. Particular attention 
should be paid to the diet. When the tendency to the forma- 
tion of acid in the primae viae is very great, beef or chicken tea 
should be in part substituted for the usual farinaceous nourish- 
ment, and all saccharine and acescent articles should be avoided. 
When painful and difficult micturition is attended with a copi- 
ous secretion of the phosphate of magnesia and ammonia— an oc- 
currence by no means uncommon, a very different treatment is 
required. In cases of this kind, the urine is usually pale, rather 
abundant, depositing a whitish or yellowish white sediment, and 
peculiarly prone to become putrid when suffered to remain at 
rest. It is almost always attended with an irritable condition of 
the general system, and with obvious derangement of the diges- 
tive organs and irregularity in the action of the bowels. Aperi- 
ents, mild tonics, opiates, and the vegetable acids, constitute the 
appropriate remedies in such cases. The bowels, in the first 
place, should be freely evacuated with rhubarb or caster oil — 
Very small doses of Dover's powders, given two or three times 
daily, generally produce an excellent effect. A half a grain of 
this article, with a grain of powdered valerian, may be given ev- 
ery six hours, to a child between two and five years of age. The 



118 OF DYSURIA. 

occasional use oflemonade, or of water sweetened with lemon 
sjrup, will sometimes assist very materially in correcting the uri- 
nary secretion. The diet should be of the mildest and most nu- 
tritious kind: considerable benefit may also be derived from the 
employment of muriated tincture of iron, in cases of this kind. I 
have known two drops of this tincture, given three times daily, 
to afford great relief in such a case. The diet should be mild and 
nutritious, and taken in very moderate quantities. Children who 
have passed through the period of primary dentition, may be al- 
lowed small portions of the tender and lean parts of beef, mut- 
ton, lamb, and chicken; but at an earlier age, the usual farina- 
cious preparations, mixed with a little of beef or chicken tea, are 
undoubtedly the most proper. Magnesia and other articles of an 
alkaline character, are decidedly improper. 

When pain and difficulty in voiding urine is not attended with 
a morbid condition of the urine either acid or alkaline, mucilagi- 
nous and slightly diuretic diluents, in conjunction with laxatives, 
and the occasional use of the warm bath, may be resorted to with 
a prospect of advantage. A weak infusion of the wild-carrot 
seed, or of parsley mixed with an equal portion of flax-seed or 
water-melon seed tea, will usually do well for this purpose. 

In some instances, extremely painful micturition depends on an 
irritable or slightly inflamed state of the extremity or orifice of 
the urethra. This difficulty is almost wholly confined to female 
children. I have quite lately witnessed a case of this kind. The 
child (about two years old) suffered severe pain every time it 
passed urine. The affection had continued seven or eight days 
before the source of the urinary difficulty was discovered. The 
orifice of the urethra was slightly swollen, red, and so extremely 
sensible, that it could not be even lightly touched, without caus- 
ing the child to shriek with pain. In cases of this kind, the pain 
and uneasiness usually continue for several minutes after the 
urine has ceased to pass off. The case just mentioned was speed- 
ily relieved by washing the inflamed and tender part with a 
strong solution of borax. The application of citrin ointment, 
weakened by mixing it with an equal portion of lard, seldom fails 
to reduce the inflammation in such cases. I have also used an 
infusion of galls, together with a watery solution of opium, with 



OF DYSURIA. 119 

an excellect effect in this variety of painful micturition. It should 
be applied with a dossil of lint. Merely covering the inflamed 
part with lard, or some mild ointment, will generally protect it 
from the painful impressions of the urine, and enable it to heal. 

During dentition the urine sometimes becomes more or less 
deeply tinged with blood, without any difficulty or pain in void- 
ing it. The appearance of blood in the urine, always excites con- 
siderable alarm; but where it is not attended with symptoms of 
irritation or inflammation in the urinary organs, it generally passes 
off without any unpleasant consequences. Small doses of the 
muriated tincture of iron, mild laxatives, and warm bathing, and 
mucilaginous drinks, seldom fail to remove it speedily. 

It is of great consequence to attend to the urinary affections 
of infants, even though they may not appear to be of a serious 
character in their immediate effects. This is particularly true 
in relation to those instances of urinary difficulty that are attend- 
ed with lithic acid, or phosphatic sediments. Dr. Prout ob- 
serves, that " children in general, and especially the children 
of dyspeptic and gouty individuals, or who inherit a tendency to 
urinary diseases, are exceedingly liable to lithic acid deposits 
in the urine. If the urine be examined, it will always be found 
to be very unnatural, and frequently loaded with lithic acid; and 
should this prove to be the fact, the case requires immediate at- 
tention, as there is much greater risk, at this period of life, than 
at any other, of the. formation of stone in the bladder." * In an- 
other place, this highly respectable writer states: every thing in 
our power ought to be done, " for preventing the effects of (li- 
thic acid deposits in the urine) and eradicating the disease in 
early life; and perhaps, it may not be deemed superfluous, here, 
to insist upon the absolute necessity there is for attending to the 
subject, when children are concerned." In such cases, it should 
be constantly borne in mind, that by proper care, the formation 
of stone in the bladder, may almost certainly be prevented; but 
by inattention, this dreadful occurrence is as certainly likely to 
take place. 

* Prout— Inquiry into the Nature and Treatment of Affections of the Urinary Organs. 
Chap. vi. s. ii. 



120 OF ENURESIS. 



CHAPTER IX. 



OF ENURESIS, OR INCONTINENCE OF URINE. 

Incontinence of urine — or rather a habit of discharging urine 
at night, while sleeping in bed, is a very common affection during 
childhood. Although very rarely attended with any particular 
uneasiness, or painful urinary irritation, it is always an extremely 
disagreeable occurrence, and the habit is apt to become so con- 
firmed, that unless early counteracted by suitable measures, it 
often continues to the age of puberty, and occasionally, even to 
adult age.- It is generally supposed that the discharge takes 
place involuntarily, without the least consciousness of its occur- 
rence; and this is doubtless frequently the case. In the majority 
of instances, however, the discharge is a voluntary act — the result 
of an active effort of volition, under the fallacious conceptions of 
a dream. In children, this disagreeable affection is very often 
associated with an unnatural condition of the urinary secretion 
itself. In those cases, especially, where the. discharge takes place 
in consequence of a voluntary effort excited by a lively dream, 
the urine, almost always contains an excess of sedimentous matter, 
particularly lithic acid, and its compounds, imparting to it an 
acrid and irritating character. " Hence," says Dr. Prout, "I have 
been led to infer, that in this species of urinary incontinence, the 
acrid properties of the urine are chiefly in fault; and that these, 
favored, perhaps, by the position of the body, and probably, also, 
by the morbid sensibility of the bladder, excite so vivid an im- 
pression on the imagination, as actually to lead to a voluntary 
effort to discharge the urine." 

The urine is seldom discharged during sleep, except when the 
individual is lying on his back. Mr. Charles Bell affirms, that 
" incontinence of urine never takes place but while the boy is 
asleep upon his back." In this position the urine gravitates back- 
wards, and presses immediately on the "sensible spot — the master- 



OF ENURESIS. 121 

spring of the muscles of the bladder, situated a little behind and 
below its orifice." 

When children neglect to pass off the urine just before going 
to bed, the bladder is apt to become distended in the course of 
the night. The impressions thus made on the bladder, pass to 
the brain, and awaken a dream occupied with a desire to mictu- 
rite, and the sphincter yields to the voluntary effort prompted 
by the desire. 

That incontinence of urine is very frequently, perhaps always 
in the first instance, excited by an acrid condition of the uri- 
nary secretion, or by distention of the bladder, in the way just 
mentioned, admits of no doubt: yet in the majority of protracted 
cases, the recurrence of the discharge depends mainly on the 
influence of habit; and in many instances, this is doubtless the 
sole cause of its repetition. 

Dr. Prout thinks that « some peculiar morbid condition of the 
urinary organs" constitutes the most frequent cause of those cases 
of nocturnal incontinence of urine, in which the discharge takes 
place involuntarily, and without any consciousness of its occur- 
rence. Cases of this kind are almost always very obstinate in 
their course. They often continue for many years, and some- 
times "even till late in life." It is by no means improbable, that 
this variety of incontinence sometimes depends on some obscure 
morbid state of the bladder-, but it can scarcely be doubted, that 
in the majority of such cases, the recurrence of the involuntary 
urinary discharges, depends chiefly or entirely on the potent in- 
fluence of habit. That the recurrence of the discharge in pro- 
tracted cases, frequently depends solely upon habit, seems to be 
demonstrated by the character of the means, most commonly suc- 
cessful in arresting its continuance. We may often remove this 
evil by exciting a slight degree of irritation about the neck of 
the bladder; so that the moment the urine begins to flow, painful 
strangury occurs, by which the person is awakened, and the 
evacuation is prevented. By repeating this for some time, the 
habit is broken up, and the involuntary discharge ceases to 



recur. 



I am entirely satisfied that this unpleasant complaint very gen- 
erally commences in consequence of an unnatural condition of the 

R 



122 OF ENURESIS. 

urine itself. When the urine becomes unusually irritating, its 
impressions on the bladder during sleep, when it becomes accu- 
mulated, are sufficiently strong to affect the sensorium commune 
in such a way as to excite a desire, and a consequent volition to 
micturate. It is not improbable that even in cases that are deemed 
strictly involuntary, and unperceived by the mind, the discharge 
takes place under an act of volition, which, however, is not remem- 
bered on waking. Persons who walk about while asleep, unques- 
tionably exercise conscious volition, though wholly unable to 
recollect any thing about it when awake. Many things have 
been done during sleep, manifestly under the control of the will, 
and probably even under the guidance of the senses, of which 
not the slightest trace is left on the mind, in the waking state. 

Treatment. — From what has been said above, it need scarcely be 
observed, that in prescribing for a case of this kind, particularly 
when of a recent character, the urine ought to be carefully in- 
spected, as a preliminary step in the adoption of a suitable plan 
of management. Should the mine be found to contain much se- 
dimentous matter, remedies ought to be employed for correcting 
the urinary secretion. If the lithic acid deposits predominate, 
small doses of magnesia, lime water, the sub-carbonate of potash, 
or of the bi-carbonate of soda, should be resorted to, in conjunc- 
tion with laxatives and other means for improving the digestive 
and hepatic functions. In cases attended with phosphatic urina- 
ry deposits, remedies calculated to invigorate the digestive organs, 
together with opiates, vegetable acids, and acescent articles of 
nourishment will be proper. By such a course of management, 
recent cases may sometimes be completely arrested. But should 
the attempt to remove the evil, in this way, fail, it is always of 
much consequence to correct the urinary secretion, when it is 
found to be in an unnatural condition. "When the incontinence 
of urine in children is associated with gravel, or an excess of se- 
dimentous matter, it is of the utmost consequence that this cir- 
cumstance be attended to, and that remedies appropriate for 
counteracting the formation of these urinary deposits should be 
employed, before any other means are used to restrain the uri- 
nary incontinence;" for without this, all other remedies will be 



OF ENURESIS. 123 

useless (Prout). When the urine has been brought to a healthy 
or natural state, and the incontinence continues to recur; or in 
cases that seem to continue under the influence of an established 
habit, recourse must be had to remedies calculated to alter the 
sensibility of the urinary organs — more especially of the neck of 
the bladder. There is no article that has been so generally pre- 
scribed for this purpose, as the tincture of cantharides ; and it is 
doubtless better adapted to produce this effect than any other 
remedy we possess. Its mode of operation in the case of this af- 
fection has already been explained above. By producing a slight 
degree of strangury, the person is awakened by the first efforts to 
urinate; and by thus repeatedly interrupting the discharge, the 
habit will finally be destroyed. From ten to fifteen drops, accord- 
ing to the age of the patient, should be given three times, in the 
course of twenty-four hours, and the dose daily increased by two 
or three drops, and continued until a burning pain is experienced 
at the neck of the bladder on passing urine. When this effect is 
produced, its use must be omitted, or continued in occasional doses, 
so as to keep up a slight degree of the urinary irritation. Should 
the strangury become too violent, suitable doses of laudanum must 
be given, at proper intervals, with emolient clysters — and the free 
use of mucilaginous diluents, such as flax-seed, or mellon-seed tea, 
barley-water, or a solution of gum arabic, and the warm hip-bath. 
Blisters applied over the sacrum, are sometimes equally beneficial. 
Incontinence of urine in children sometimes depends on a mor- 
bidly irritable state of the bladder. The patient is during the 
day more or less harassed with a frequent desire to urinate, and 
the discharge is always accompanied with considerable uneasiness, 
and sometimes with much pain. These cases are usually associ- 
ated with a morbid condition of the urine — sometimes with an 
excess of lithic acid, and occasionally with phosphatic deposits. 
Instances of this kind must be managed in the way stated above. 
The use of cantharides, or of other remedies calculated to irritate 
the neck of the bladder, would be highly improper in such cases. 
An irritable state of the bladder may, however, occur, without any 
morbid appearances in the urine, and give rise to urinary inconti- 
nence. Here, the remedies, proper for counteracting the secre- 
tion of the lithic acid, or phosphatic sediments would, probably, 



124 OF ENURESIS. 

prove injurious. In such cases recourse must be had to the warm 
bath — cooling laxatives, opiates, particularly Dover's powder, the 
application of a stimulating plaster over the sacrum, and a mild 
and digestible diet. 

When incontinence of urine is attended with irritation of the 
rectum by ascarides, means should be used to remove these an- 
noying little worms out of the bowels. I once attended a little 
girl who was for several months much troubled with uneasiness 
on passing water, and scarcely a night passed, without a discharge 
of urine during sleep. I at length learned that she was also 
greatly annoyed by ascarides. By the use of aloetic injections a 
large mass of them were brought away from the rectum, and the 
urinary difficulty and incontinence disappeared, for eight or nine 
months, when they returned, and were again removed by the same 
means. 

Whatever means may be employed for the cure of nocturnal 
incontinence of urine, care should always be taken to accustom 
the patient to sleep upon his side or the belly. In this position 
the urine gravitates towards the fundus of the bladder, and does 
not rest upon the sensible spot, referred to above; and the patient 
is therefore not so apt "to be excited to dream of making urine, 
and to exert a voluntary effort, to urinate, as when he lies on 
his back." Children should always be required to empty the blad- 
der just before going to bed, and when they awaken at night 
they ought to be taught, to rise and pass off the urine. By a 
careful attention to these things, the occurrence of the disordei 
may generally be prevented. 



OF DENTITION. 125 



CHAPTER X. 



OF DENTITION. 



The development and progress of the teeth through the gums, 
takes place in a very gradual manner. The germs of the teeth 
present themselves in the form of small follicles, containing a 
pulpy substance, attached to, or continuous with the fascicle of 
vessels and nerves which penetrate the cells or alveoli in which 
they are placed. The period at which these germs first make 
their appearance in the fcetal jaws has not been satisfactorily de- 
termined. It is sufficiently ascertained, however, that the first 
traces of ossification, very rarely occur previous to the fourth 
month; and it is equally uncommon to find the commencement 
of this process delayed beyond the middle of the fifth month. At 
birth, the development of the primary teeth is already consid- 
erably advanced. The whole crown is formed, but the root is 
still imperfect, consisting of a short and thick tubular projection, 
with very thin sides. 

The number of these primary teeth is twenty — namely, four 
incisors or cutting teeth, two cuspid or eye teeth, and four grind- 
ing teeth in each jaw. Between the appearance of the first and 
the lastofthe primary or milk teeth, several years usually intervene. 
The first seldom protrude through the gums before the fourth 
month, and the last generally make their appearance about the 
end of the second year. The two middle cutting teeth of the 
lower jaw, are usually the first that make their appearance. In 
the course of three or four weeks afterwards, the corresponding 
incisors of the upper jaw protrude through the gums. These, in 
a few weeks more, are succeeded by the lateral cutting teeth of 
the lower jaw; and in a short time afterwards, the lateral inci- 
sors of the upper jaw also pierce the gums. In the course of 



126 OF DENTITION. 

from about two to four months after the eight cutting teeth have 
made their appearance, the anterior grinders of the lower jaw 
" elevate their white surfaces above the gums," leaving vacant 
spaces between them and the two lateral incisors, for the cuspids 
or eye teeth. Soon afterwards, the corresponding grinders of 
the upper jaw also make their appearance. The cuspids or eye 
teeth next come out, those of the lower jaw preceding the upper 
ones. Finally, the second grinders pass through the gums, and 
terminate the process of primary dentition. 

Although the general progress and order of dentition is such 
as has just been stated, yet great diversity occurs in different in- 
dividuals, both in relation to the time at which the teeth pro- 
trude through the gums, and the order or succession of their 
appearance. In some instances, the first incisors appear as early 
as the second month, and in others, they do not make their appear- 
ance until the seventh or eighth month. The usual period of 
their appearance, however, is about the fifth or sixth month. — 
The irregularities, in this respect, are sometimes very great. 
Infants have been born with one or more well-formed teeth pro- 
truded. Van Swieten mentions cases of this kind, on the authority 
of Pliny, Marcellus Donatus, Colombo, &c. ; and Haller and 
Voigtel refer to a great number of similar instances. I have 
myself seen an infant furnished with two well-shaped incisors, as 
early as the fourth week after birth. The instances of very tardy 
dentition are sometimes equally remarkable. I have a child now 
under my care, which has, as yet, not a single tooth, although up- 
wards of eleven months old. Van Swieten mentions an instance, in 
which the first teeth did not make their appearance until the child 
was upwards of nineteen months old; and many cases of much 
greater delay in the appearance of the teeth, are recorded by 
Haller, Voigtel, and other writers. 

With regard to the order in which the teeth are protruded, 
deviations from the ordinary course, as stated above, are by no 
means uncommon. In some instances, the two lateral cutting 
teeth of the lower jaw, make their appearance before the mid- 
dle ones. Sometimes the incisors of the upper jaw precede those 
of the lower; and occasionally the eye teeth come out before 
the lateral cutting teeth. It is rare, however, to find the eye 



OF DENTITION. 127 

teeth advanced through the gums before the first grinders, although, 
occasionally, this takes place. Instances are sometimes met 
with in which all the incisors pierce the gums almost simul- 
taneously. 

Although a process of physical development, and, therefore, 
strictly in accordance with the regular progress of nature, denti- 
tion is, nevertheless, almost invariably attended with more or less 
obvious deviation from a healthy condition of the system. The 
progress of the teeth through the gums is usually accompanied 
with a manifest increase of the general irritability of the system. 
The mouth is generally very hot, and the saliva secreted in great 
abundance. In many instances diarrhcea occurs; and in female 
infants, a slight mucous or leucorrhceal discharge from the vulva, 
is not uncommon. The infant evidently experiences an unplea- 
sant tickling sensation in the gums, as may be inferred from the 
eagerness with which it bites upon hard substances, and the evi- 
dent gratification it derives from having its gums firmly pressed 
and rubbed with the point of a finger. The sharp margin of the 
gums gradually expands and becomes flatter, and, in difficult 
cases, inflamed and swollen, as the teeth approach the sur- 
face. The infant manifests an irritable and fretful temper; slight 
exciting causes are apt to give rise to febrile irritation, and one 
or both cheeks are often flushed, more especially towards evening 
and after a full meal. When asleep, the child frequently starts 
as from sudden fright, and the expression of the countenance un- 
dergoes repeated changes. 

The general and local disturbances accompanying dentition, 
are, however, often of so slight a character, as to require no atten- 
tion, or to escape notice altogether. This is most apt to be the 
case in children whose constitutional habit is healthy, and who 
have been nourished with mild and appropriate food, and in 
whom the advance of the teeth through the gums is attended 
with a free secretion of saliva, and moderate loosness or diarrhcea. 
These evacuations are, in general, decidedly salutary. The free 
discharge of saliva has a direct tendency to relieve the irritable 
and congested capillaries of the gums and mouth, and to derive 
the blood from the brain, and moderate its irritative condition. 
The diarrhoea may prove beneficial, by " determining the circu- 



!28 OF DENTITION. 

lation from the head to the intestines, and particularly by its 
effects in lessening the quantity of blood in the system, and dimin- 
ishing the strong action of the heart and arteries." 

Even the most favorable instances, however, are attended with 
an increased susceptibility to the injurious influence of irritating 
or exciting causes; and hence all diseases, whatever may be their 
cause or origin, are apt to assume a more violent character du- 
ring dentition than at other periods. There can be no doubt 
that many complaints, which at other periods would have termi- 
nated favorably, often acquire a fatal violence from that irritable 
and irritative condition of the system, which attends difficult den- 
tition. From this circumstance, as well as from the direct ten- 
dency of dentition to originate violent affections, the period during 
which this process is going on, is justly regarded as one of the 
most perilous stages of life. It has been computed that one tenth, 
at least, of all the deaths which occur during childhood, may be 
fairly ascribed to dentition; and it does not appear to me that 
this is an exaggerated estimate. 

When the gums become inflamed, swollen, and painful, and the 
secretion of saliva scanty, with torpor of the bowels, the whole 
organization, generally, sympathizes strongly with the local affec- 
tion, and the nervous system especially is liable to great and dan- 
gerous irritation. Indeed, when from the influence of previous 
morbific causes, the system has become feeble, and unnaturally 
irritable, the most alarming consequences sometimes result from 
the irritation of the advancing teeth, before any signs of irritation 
and inflammation are discoverable in the gums. 

Among the various circumstances which are apt to render den- 
tition difficult and dangerous in its consequences, a deranged or 
dyspeptic state of the digestive organs, from errors in diet, is 
probably the most common and pernicious in its tendency. Chil- 
dren who are nursed exclusively at the breast, are, in general, 
much less apt to suffer inconvenience or disease, from dentition, 
than those who are either wholly, or in part, nourished with arti- 
ficial food. When the digestive organs are habitually disordered, 
from the use of inappropriate articles of food, the risk of serious 
consequences from dentition is always very conside;«able. The 
general system, usually, becomes enfeebled and morbidly irritable, 



OF DENTITION. 129 

by a continued course of improper nourishment; and in this con- 
dition the local irritation of the advancing teeth is not only pecu- 
liarly apt to give rise to general irritative affections, but by its 
reaction on the stomach and bowels, adds also greatly to the dis- 
ordered state of these organs, and ultimately, often produces vio- 
lent and highly dangerous affections. In robust and healthy 
children, the use of stimulating articles of nourishment and drink 
is calculated to do much injury, in this respect, independent of 
its tendency to derange the digestive organs, by increasing the 
phlogistic condition of the system, and promoting the occurrence 
of febrile and inflammatory affections, from the local irritation in 
the gums. A close and contaminated atmosphere, more especially 
when aided by high temperature, has a decided tendency to 
increase the difficulty and morbid consequences of dentition. — 
Children who reside in populous cities, or who are much confined 
to close and ill-ventilated apartments, are much more liable to 
unpleasant consequences from teething, than those who enjoy the 
pure and salubrious air of the country. The tendency of inac- 
tivity, impure air, and high atmospheric temperature, to increase 
the irritability of the system, and predispose it to the injurious 
-nfluence of irritating causes, is well known. Dentition can sel- 
dom go on without giving rise to considerable disturbances in the 
system, where these causes are in full and continued operation 
during the process. The practice of keeping the heads of infants 
very warm, by flannel caps, or " sleeping on very soft pillows, 
which nearly envelop their heads," may do injury during denti- 
tion, by favoring the determination of blood to the head, and 
thereby increasing the liability to inflammatory irritation of the 
brain, &c. 

The morbid, sympathetic effects of difficult dentition are very 
various. In robust, full, and otherwise healthy infants, the general 
disturbances, usually, consist in slight febrile irritation, particularly 
towards night, attended with a frequent, quick and sharp pulse; 
a very warm and somewhat dry skin, more or less costiveness, 
increased thirst, flushed cheeks, dull and heavy eyes, and a fretful 
and irritable temper. Cases of this kind are seldom accompanied 
with a copious secretion of saliva; on the contrary, the free dis- 
charge of this secretion, or the supervention of moderate diarrhoea, 

S 



130 OF DENTITION. 

almost invariably mitigates the general irritative condition, to a 
very obvious degree. In some instances, the brain sympathizes 
so strongly with the local affection, as to give rise to the usual 
phenomena of incipient arachnitis or acute dropsy of the head. 
In cases attended with this state of cerebral erethism, the child 
generally sleeps with its eyes half open, a circumscribed flush 
frequently appears on one or both cheeks, the eyes become 
slightly injected, and unusually sensible to light; the eye-brows 
are often contracted into a peculiar frown, accompanied with a 
discontented and anxious expression of the countenance; and the 
child is extremely fretful and irascible; when asleep, it often 
starts suddenly and screams out violently, or moans as if in pain; 
it is frequently observed to raise its hands and press them against 
the forehead; vomiting is apt to occur on rising suddenly from a 
recumbent to a sitting or erect posture, or after taking stimu- 
lating articles of nourishment; and the bowels are almost invaria- 
bly in a disordered condition, being either torpid, or disturbed 
with griping, colic-pains and diarrhoea. The pulse is frequent, 
quick, and contracted — the temperature of the skin variable, the 
hands and feet being, at times, remarkably cool, whilst the head 
and body are preternaturally warm. Cases of this kind are 
always attended with considerable danger. When neglected or 
mismanaged, particularly in relation to the diet, they are apt to 
terminate in fatal oppression of the brain, from effusion into its 
cavities and upon its surface, or disorganization of its structure. 
In some instances of difficult dentition, attended with an irrita- 
ted condition of the brain, a remarkable swelling occurs on the 
hands and feet, which as the case advances, generally becomes 
associated with symptoms of alarming and frequently fatal ner- 
vous irritation. This swelling " has a considerable degree of 
roundness and elevation, and looks like that sort of tumor which 
might rise, on the same parts, from a blow or contusion. It seems 
to arise suddenly, as it has, generally, this roundness and eleva- 
tion, from the time of its first attracting observation." When 
first observed it has somewhat of a mottled, lived, and purplish 
color, resembling the chilled hand of a full and healthy child after 
exposure to a cold and frosty atmosphere. It feels cold, at least 
it has no inflammatory heat and does not appear to be morbidly 



OF DENTITION. 131 

sensible, or to give any pain to the child when handled. It does 
not pit on pressure, but rather gives the sensation of firmness and 
resistance. The swellings are confined to the anconal aspect of 
the metacarpus of the hands, and the rotular aspect of the meta- 
tarsus of the feet, terminating abruptly at the carpus and tarsus. 
The duration of these tumors is very various in different 
cases. Sometimes they disappear in three or four days — at others 
they continue for many weeks without either increase or diminu- 
tion; and occasionally they disappear and return again, at short 
intervals for a number of weeks. In some cases these swellings 
pass off without any unpleasant or alarming consequences. More 
frequently, however, symptoms of a much more formidable nature 
ensue — consisting of a peculiar spasmodic affection commencing 
in the flexors of the hands and feet, and gradually extending itself 
until it terminates in general convulsions or tetanic spasms of the 
whole body. The reader is referred to the chapter "On Convul- 
sions," in this work, where this very singular affection is fully de- 
scribed under the name of Pedo-carpal Convulsions of Infants.* 

The occurrence of convulsions from difficult dentition is very 
common. When they come on suddenly, and are attended with 
a full and flushed countenance, they are in general, much less dan- 
gerous, than when they are preceded, for some time, with symp- 
toms of active cerebral irritation, and accompanied, with a pale 
and contracted aspect of the countenance. Cases of the former 
kind generally depend on simple irritation and vascular tumes- 
cence of the brain; whereas the latter are often connected with 
slow meningeal inflammation, effusion, or disorganization of some 
portion of the brain. When the child remains in a state of 
stupor or partial insensibility, with its eyes half open and turned 
up under the upper lids, for a considerable time after the parox- 
ysm has subsided— and particularly when along with these symp- 
toms, the respiration is very irregular with an occasional deep 
moaning sigh, and a very slow or extremely rapid and small 
pulse, the chances of a favorable termination are always extremely 
slender. When on the other hand the infant, soon after emer- 

* Notes on the Swelling of the Tops of the Hands and Feet, &c. By Geo. Kellie,M. D. 
Edinburg Medical and Surgical Jour. vol. 12. p. 449. 



132 OF DENTITION. 

ging from a fit, takes notice of surrounding objects, and breathes 
freely and regularly, without any particular manifestations of sen- 
sorial torpor and drowsiness, the probability of a favorable re- 
sult, will be very considerable. Nothing tends more strongly to 
favor the occurrence of convulsions during dentition, than gastric 
or intestinal irritation, from the use of improper articles of nour- 
ishment, or from overloading the stomach. Children who are 
under the influence of difficult dentition, seldom enjoy a perfectly 
healthy state of the digestive organs, even under the most careful 
and judicious dietetic management. The stomach during this 
process, is often morbidly irritable, and hence errors in diet are 
much more apt to produce injurious consequences during this, 
than at any other period of life. So far as my own observations 
enable me to form an opinion, I am inclined to think that, the 
majority of instances of convulsions, usually ascribed to the sole ir- 
ritation of dentition, are in fact excited by improper or immoderate 
alimentary ingesta. When the diarrhoea which frequently accom- 
panies dentition is suddenly arrested by astringents, opiates &c. 
the liability to convulsions is always much increased, more espe- 
cially in robust and plethoric infants. The same thing occurs, 
when from cold, or some other cause, the salivary secretion is 
suddenly checked or suspended, and the bowels remain costive. 
In general, convulsions are much more apt to occur during the 
eruption of the first grinders and eye-teeth, than while the inci- 
sors are making their way through the gums. This may arise, 
in part at least, from the circumstance that during the cutting of 
the incisors, children are as yet usually nourished exclusively at the 
breast; whilst during the latter stage of dentition, when the grin- 
ders and eye-teeth are advancing through the gums, they are 
generally weaned, and therefore much more exposed to gastro- 
intestinal irritation from improper articles of food. 

Various eruptions on the skin are among the most common 
morbid consequences of difficult dentition. Of these, the crusla 
lactea is by far the most disagreeable and unmanageable. That 
this affection is intimately associated with dentition, is manifest 
from the fact, that it very rarely makes its appearance previous to 
the commencement of dentition, and never, I believe, after the 
process has been completed. Excoriations behind the ears, and 



OF DENTITION. 133 

the various species of strophulus — particularly the strophulus con- 
fertus or tooth rash, are, also, very common during this period of 
infancy. The Strophuli are almost invariably accompanied with 
derangement of the digestive organs, and diarrhoea; but the two 
former affections, namely crusta lactea and excoriations about 
the ears are generally attended with a strong appetite and consi- 
derable torpor of the bowels. 

Infants are also liable to a peculiar croupy affection during 
dentition, which is evidently of a spasmodic character, and de- 
pendent on cerebral irritation. In some instances, the singular 
swelling of the hands and feet mentioned above, becomes associ- 
ated with occasional attacks of this croupy affection, about the 
time that the disease is assuming a distinctly spasmodic character. 
This form of croup, which has been aptly called "cerebral croup," 
is most apt to come on at night or early in the morning. It is 
attended with extremely difficult respiration and the hoarse and 
sonorous cough of ordinary croup. The attack is always very 
sudden, and generally of short duration, seldom continuing beyond 
fifteen or twenty minutes, and often not above a minute or two. 
I attended a child about three years ago, which, during the erup- 
tion of the eye teeth, was seized with an attack of spasmodic 
croup, almost every night, for six or seven weeks. As soon as the 
eruption of the eye-teeth was completed, the croupy affection 
ceased to recur. Under the head of croup, this singular malady 
is more circumstantially described. Slow and difficult dentition 
is sometimes attended with a very troublesome spasmodic or 
" nervous" cough, which comes on in sudden and violent parox- 
ysms, at irregular and sometimes remote intervals. The breath- 
ing during the fit, is oppressed and suffocative; and the cough 
usually continues until the contents of the stomach are thrown off. 
At night the child is generally very restless, and the breathing 
peculiarly irregular, being now, extremely hurried and short, and 
then, slow, interrupted, sighing and moaning. In several remark- 
able cases of this kind— one of them in my own family,— the uri- 
nary secretion was unusually small, and frequently voided with evi- 
dent pain. The cough generally continues to recur, until the teeth 
are all cut. I have never known it to continue after this process 
was completed. In many cases of spasmodic cough during diffi- 



134 OF DENTITION. 

cult dentition, the principal irritation is evidently located in the 
stomach. In these instances, the epigastrium is distended, the 
stomach and bowels disordered and the alvine evacuations 
glairy and bilious. The fits of coughing are most apt to occur a 
short time after taking nourishment, and they usually continue 
until the greater part of what was received into the stomach, is 
thrown off by vomiting. There is seldom much saliva secreted 
in cases of this kind, and the tongue, generally, presents a bright 
red color along the edges and point, with a coat of thin white fur 
along its middle. 

In some instances, of painful dentition, the urinary organs sym- 
pathize strongly with the local irritation in the gums. This is 
most apt to be the case, when the digestive powers are weak, 
and the primse viae habitually charged with acidity. The con- 
nection between habitual acidity in the stomach and bowels, and 
urinary difficulties, has already been pointed out in the chapter 
on "ZtysMn'a." The urine, in such cases is often loaded with an 
excess of lithic acid, or its compounds, and, on this account fre- 
quently so irritating, as to give rise to severe burning pain in the 
neck of the bladder and urethra on being voided. Occasionally, 
however, an opposite condition of the urine obtains. The urinary 
deposits are alkaline or earthy, and the urine is secreted in 
great abundance, assuming the character of diabetes insipidus. 
This latter condition of the urine, is seldom attended with any 
manifestations of febrile irritation; the hands and feet are usually 
cool, the system relaxed and languid, and the countenance pale 
and expressive of distress or buffering. 

Fever, as has already been stated, is perhaps the most common 
sympathetic affection of difficult dentition. It seldom, however, 
assumes a vehement character, unless there are other sources of 
febrile irritation present. It is generally slow, irregular, change- 
able, intermitting or remitting — presenting the usual phenomena 
of chronic irritative fever, from slight local affections. The ma- 
jority of instances of fever that occur during dentition, are exci- 
ted, or at least greatly promoted by other causes. In that irrita- 
ble state of the system, which usually attends the progress of the 
teeth through the gums, a slight accession of other sources of 
febrific irritation, will give rise to fever. 



OF DENTITION. 135 

Management. — Throughout the whole course of dentition partic- 
ular care should be taken to avoid every source of undue excite- 
ment or irritation. Even the most regular and mild cases are 
usually attended with an increased susceptibility to the influence 
of exciting or irritating causes. The stomach and bowels, especi- 
ally, are apt to acquire an increased predisposition to the injurious 
operation of causes of this kind. Slight errors in diet are apt to 
disorder the digestive organs, during this period; and the occur- 
rence of gastro-intestinal irritation is always peculiarly unfavora- 
ble to the easy progress of dentition. In all instances, therefore, 
the diet ought to be as simple and unirritating as possible. If the 
nurse furnishes a sufficient quantity of wholesome milk, nothing but 
this congenial nourishment ought to be allowed during the first 
period of dentition — that is until all the incisors at least, are pro- 
truded. Weaning should never be effected during the active pro- 
gress of dentition. In general the most favorable period for 
weaning, is soon after all the incisors have made their appear- 
ance. Should it become necessary to resort to the use of artifi- 
cial nourishment, in addition to that obtained at the breast, no- 
thing can be more appropriate than the simple mixture of milk 
and water mentioned in the chapter " On the Nourishment of In- 
fants." All solid articles of food ought to be rigidly avoided — 
more especially during the primary stage of dentition. After all 
the incisors have made their appearance, the child may occasion- 
ally take small portions of oatmeal gruel, crackers grated and 
dissolved in warm milk and water, barley water, and liquid pre- 
parations of arrow root, tapioca, or sago, provided the general 
and local irritation be not considerable. Moderation as to quan- 
tity also, is an important requisite to the proper dietetic manage- 
ment of infants during dentition. A full diet may do harm by 
increasing the general plethora and febrile tendency of the sys- 
tem, or by oppressing the digestive organs and giving rise to a 
disordered state of the stomach and bowels. The great objects 
to be kept in view, while dentition is going on, is to guard 
against every thing which may have a tendency to render the 
child feeble and morbidly irritable, or increase the fulness and 
inflammatory diathesis of the system. 
Regular exercise by gestation in the open air, has an excellent 



136 OF DENTITION. 

prophylactic tendency during dentition* When the weather is 
sufficiently mild and dry, the infant, if free from fever, ought to 
be daily exercised in the fresh and open air, by carrying, or 
riding it in a carriage. Inactivity and confinement to an impure 
and stagnant atmosphere are decidedly unfavorable to the easy 
and undisturbed progress of dentition. Children who enjoy suita- 
ble exercise, in the salubrious air of the country, almost always, 
pass through this period, with less inconvenience and danger than 
those who are confined to the contaminated atmosphere of popu- 
lous cities. It is to be observed, however, that exercise is not 
recommended in cases attended with distinct fever, or with a de- 
cided tendency to secondary inflammations. It is to be regarded 
as a preventive measure — as a means for avoiding the occurrence 
of morbid irritability, and irritation, rather than for removing 
them when once developed. With this view, much benefit may 
unquestionably be derived from it. When aided by the influence 
of a salubrious air, it tends, in no small degree, to fortify the ge- 
neral powers of the system, and to prevent that feeble and irri- 
table condition, which is so apt to occur during difficult denti- 
tion, and so favorable to the occurrence of alarming irritative 
affections. 

Care should also be taken to avoid, as much as possible, every 
thing that may cause a preternatural determination of blood to the 
brain. The head ought to be kept cool. During warm weather, 
no caps should be worn; and at night, or when sleeping, the head 
should be suffered to remain uncovered. A very soft and large 
pillow of feathers, so as to cause it to lap round the infant's head, 
is particularly improper. The head must also be carefully se- 
cured from the direct rays of the sun when the child is carried 
out into the open air. A light straw hat, is decidedly the best 
covering for infants during the warm seasons. During cold 
weather caps, made of very thin materials may be worn within 
doors; and when the child is taken out, its head should be further 
protected against the cold, by a thin cloth cap, while the feet are 
kept as warm as possible by thick flannel stockings and shoes. 

Costiveness must be obviated by enemata, and the occasional 
administration of a mild purgative. Much care is required, how- 
ever, lest, in the anxiety to remedy this state of the bowels, a 



OF DENTITION. 137 

more serious one be not substituted, by harsh and repeated pur- 
gations. I am certain that I have seen much harm done in this 
way. At no period of life, perhaps, are strong purges, so apt to 
give rise to intestinal irritation, as during the active progress of 
dentition. Habitual costiveness during dentition, is very generally 
attended with a deficient secretion of bile. The stools frequently 
present a whitish or clay-colored appearance and the urine is usu- 
ally loaded with bilious matter. In cases of this kind, a small 
portion of calomel should be given every third or fourth evening 
and a moderate dose of castor oil or magnesia on the following 
morning. From one to two grains of calomel, will in general, 
suffice for this purpose. During the intermediate periods purga- 
tive enemata ought to be administered, so as to procure at least 
two free evacuations every twenty-four hours. Small doses of 
epsom salts dissolved in some bland and slightly mucilaginous 
fluid forms an excellent laxative in cases attended with febrile 
irritation. In the employment of calomel during dentition great 
care should be taken, that it be not carried to the extent of in- 
flaming the gums, or producing a general mercurial action on the 
system. I have witnessed several highly distressing instances of 
extensive ulceration and sloughing of the gums and cheeks, in 
consequence of the incautious employment of calomel, while the 
system was under the influence of dentition. 

If moderate diarrhoea occurs, it ought not to be checked or ar- 
rested, unless the child be in a very feeble condition from previous 
sickness. But even in this case, it should always be subdued in a 
gradual and gentle manner. Its tendency, as has already been 
stated, is in general, decidedly favorable, both by moderating the 
general febrile disposition of the system, and by counteracting the 
preternatural flow of blood to the head. When suddenly arrested 
by opiates or astringents, the local and general disturbances sel- 
dom fail to acquire a more severe and dangerous character. Con- 
vulsions, fever, and inflammatory affections of the brain, are 
among the evil consequences which are apt to result from the 
injudicious interference with the diarrhoeal affection. In many 
instances, however, the diarrhoea assumes so violent a character, 
p« to exhaust and disorder the system to a very dangerous extent. 
In cases of this kind, remedial assistance is indispensable. When- 



j 38 OF DENTITION. 

ever the system is obviously debilitated and relaxed by this affec- 
tion, measures should be adopted to moderate its violence. Unless 
the necessity of prompt and energetic measures be decidedly in- 
dicated, the excessive action of the bowels ought to be moderated 
in a gradual manner; and when the complaint can be reduced to 
a mild state, no attempt should be made to arrest its course wholly. 
Small doses of ipecacuanna, in combination with prepared chalk 
and minute portions of calomel, have, in general, succeeded bet- 
ter, in my hands, in cases of this kind, than any other remedy. A 
powder composed of a fourth of a grain of ipecacuanna, one sixth 
of a grain of calomel, and four or five grains of prepared chalk, 
should be given every three or four hours until the diarrhoea is 
sufficiently moderated. By continuing the exhibition of two or 
three doses daily, the complaint may generally be kept in a suffi- 
ciently moderate state, until the advancing teeth are protruded. 
I have rarely known a violent case of diarrhoea wholly arrested 
during the active progress of dentition, without an obvious increase 
of the general and local irritation. In cases of decidedly difficult 
dentition, attended with an irritated state of the nervous and vas- 
cular systems, it is generally extremely difficult to manage the 
diarrhoea without either suffering mischief from the exhausting 
effects of the bowel complaint, or aggravating the general and lo- 
cal irritative affections by giving it too great and sudden a check. 
A striking example of the correctness of this observation occurred 
to me not more than ten days ago. The infant was cutting the 
first molares, with considerable difficulty, though nothing of a 
dangerous character occurred except a diarrhoea, which in a short 
time became extremely violent and prostrating. I prescribed the 
above powders of ipecac, chalk and calomel, which had the effect 
of moderating the complaint considerably, though not to a sufficient 
extent. As this remedy did not seem to do any further good, I 
advised a decoction of the root of geranium maculatum in milk. 
This was given, and the bowel complaint was soon entirely arrest- 
ed. In about ten hours after the complaint was thus stopped, a 
violent paroxysm of convulsions occurred, which terminated in a 
torpid or comatose condition ; and although an active purgative and 
repeated enemata were administered, a second fit of convulsions 
ensued and terminated the life of the little sufferer. 



OF DENTITION. 139 

The child's mouth ought to be washed out with fresh water 
every morning. This is always very grateful, and tends to mod- 
erate the uncomfortable heat and irritation of the mouth. The 
practice of putting some hard substance into the child's hands, to 
press and rub its gums with, is proper, and should never be neg- 
lected. A piece of smooth coral, ivory, orris root, or firm-grained 
wood may be used for this purpose. The substance ought to be 
smooth or polished, and of such a size and shape as to enable the 
child to hold it firmly with the hand, and prevent its slipping back 
into the fauces or throat. An ivory ring, about an inch and a 
quarter in diameter, is an excellent contrivance for this purpose. 
The ring may be suspended round the child's neck, so as to be al- 
ways within its reach. This practice has been condemned by 
some writers, on account of its supposed tendency to harden the 
gums, just as the soles of the feet and palms of the hands are indu- 
rated by much walking and manual labor. This apprehension is, 
however, entirely unfounded. The tendency of compression and 
friction is rather to promote the absorption of the gums, than to 
consolidate and render them more resisting to the advancing teeth. 
Indeed the instinctive and apparently irresistible propensity 
which all children manifest to press and rub their gums firmly, 
upon everything they lay hold of; and the very obvious relief and 
gratification which they derive from it, may be regarded as a suffi- 
cient warranty that the practice is not only harmless, but decided- 
ly beneficial and desirable. Friction and pressure manifestly 
moderate the painful sensations of the gums; and they may do 
good, also, by promoting the free secretion of saliva, and thereby 
diminishing the heat and irritation of the mouth. 

From time to time, the gums should, in all cases, be carefully 
inspected; and when found to be in an inflamed and swollen con- 
dition, they ought to be promptly and freely divided with a lan- 
cet, even though no unpleasant consequences be produced by the 
local irritation. When the gums are in this condition, a slight, 
additional exciting cause, will be apt to give rise to dangerous 
affections. An error in diet, an accidental derangement of the 
digestive organs, or a slight cold, may bring on an attack of con- 
vulsions, of fever, or of profuse and exhausting vomiting and purg- 
ing. By a timely division of the inflamed and swollen portion of the 



140 OF DENTITION. 

gums, the liability to consequences of this kind, will be much 
diminished. During the actual presence of these and other affec- 
tions depending on difficult dentition, a division of the gums should, 
on no account, be neglected, if they are manifestly distended, or in 
a state of inflammatory irritation. The diseases of dentition ap- 
pear to depend, mainly, on the distention of the membrane inves- 
ting the crown of the teeth, and pressure upon the pulp, nerves 
and vessels at the bottom of the socket, in consequence of the re- 
sistance which the advancing teeth experience, from the tension 
and firmness of superincumbent gums. By dividing the gums, this 
pressure and distension is moderated, and if no other exciting 
cause be present, speedy and important relief will frequently en- 
sue. Little or no advantage, however, can be expected from this 
operation, so long as the edge of the gums is sharp and wholly 
free from inflammation. It is not necessary, indeed, that there 
should be distinct swelling and inflammation present, to render 
this measure proper or useful. If the part over the advancing 
teeth is expanded, or thickened and tense, relief may be expected 
from the operation, although no decided marks of inflammation be 
present — in other words, if the teeth have approached near the 
surface, and unpleasant or alarming sympathetic affections occur, 
it will be proper to divide the gums freely. "Under every cir- 
cumstance, of indisposition arising from dentition, the lancing of 
the gums ought never to be omitted. As soon as the gum is lanced, 
and the membrane is divided, the tooth obtains an increased room, 
the pressure is immediately taken off from the socket, and the 
cause of the irritation is removed" (Fox). 

In reply to the objections that have been urged against the 
propriety and usefulness of this operation, I offer the following 
remarks from the writer just quoted. "It is very surprising, that 
notwithstanding the manifest advantage, which attends the lancing 
of the gums, in cases of painful dentition, there are persons who 
entertain strange prejudices against this safe and important source 
of relief. But the uniform experience of its good effects, and no 
instance of its doing harm ever having occurred, should produce 
an unanimous consent for adopting it. Some persons object to the 
operation, on account of the pain which it will occasion to the 
child, not considering that the inflammation produced by the re- 



OF DENTITION. 141 

sistance of the gum to the tooth, is far more acute, than dividing 
the gum with a sharp instrument. Others suppose that the form- 
ation of the teeth is injured, and that they are more liable to de- 
cay; but neither of these circumstances can occur; for at the time 
the tooth is about to pass through, the enamel is completely form- 
ed, and no injury can be done to the formation of the fang, which 
is always continued for some time after the appearance of the 
crown." 

" When it is necessary to lance the gums sometime before the 
teeth are quite ready to appear; they unite, and in this case the 
cicatrix has been said to impede the progress of the tooth, present- 
ing a greater resistance than the gums, in their natural state; but 
it is now certainly known that a newly formed part, or cicatrix, 
always gives way sooner to the process of absorption than the sur- 
rounding parts, and hence the passage of the tooth is facilitated. 
The hemorrhage which is occasioned by the operation, is scarcely 
ever considerable, but is always beneficial: the vessels become un- 
loaded, and the inflammation is always soon diminished." 

Under an idea that the cicatrix may impede the protrusion of 
the tooth, some advise that the division of the gums should be made 
at the side near the edge, rather than directly over the crown of 
the advancing teeth. This, however, is not only unnecessary, but 
unfavorable to success. The incision should be made in the direc- 
tion of the gums, and immediately over the crown of the teeth. 
A single incision will be sufficient for the incisors; but when the 
molares are near protruding, and the gum is swollen and tense, a 
crucial incision may be advantageous. Mere scarification can 
afford but little advantage. The gums must be freely divided, 
down to the teeth. The principal difficulty arises from the dis- 
tension of the firm membrane stretched over the teeth; and unless 
this be divided along with the gums, the operation will fail to pro- 
cure the full benefit which it is capable of affording. 

When convulsions occur during dentition, the gums should be 
immediately divided if they exhibit any signs of inflammation 
or distension from the advancing teeth. Some writers recommend 
this operation in all instances of convulsions, while the process 
of teething is going on, whether marks of irritation or distension 
of the gum be present or not. "The advantages of this operation 



142 OF DENTITION. 

are so great," says Underwood, "that whenever convulsions take 
place about the usual period of dentition, recourse ought always 
to be had to it, though by an examination of the gums there be no 
certain evidence of the convulsions being owing to such a cause. 
At any rate the operation can do no harm, even at any period; 
and should the shooting of teeth be only an aggravation of the 
true cause of the disease, lancing the gums must be attended 
with advantage." I am, however, convinced from experience, 
that cutting down through the gums, at so early a period, is always 
entirely useless; and I have known very troublesome and even 
alarming hemorrhage to occur from a deep incision, while the 
teeth were yet far from protruding, and the gum wholly free from 
the enlargement or distention which accompanies the advanced 
stage of dentition. It is not necessary, however, that there should 
be obvious inflammation and swelling present, to render this ope- 
ration proper, or likely to afford benefit. Whenever, from the 
fulness of the gum, it appears that the tooth is near the surface, a 
free incision should undoubtedly be made, if convulsions or other 
alarming affections supervene. For a full account of the mode 
of managing convulsions from dentition, the reader is referred to 
the chapter "On Convulsions." 

Should the child become affected with cutaneous diseases, while 
under the influence of dentition, the utmost caution ought to be 
observed, in the employment of external remedial applications. 
This is particularly important, in relation to discharging sores be- 
hind the ears, and scabby eruptions about the head. The appli- 
cation of astringent, drying, or repelling substances, may lead to 
the most violent and dangerous consequences. Indeed these affec- 
tions, like the copious secretion of saliva, may have a favorable 
effect, by deriving the irritation and preternatural flow of blood, 
from the brain and other internal organs. If the external affection 
be suppressed, the sympathetic irritation will not be subdued, but 
only transferred to some other part of the system. If it falls on 
the brain, as it often does, convulsions, or meningitis (dropsy of the 
brain) may be the result; if on the lungs, severe pneumonic or 
cynancheal affections maybe the consequence; and, if the stom- 
ach and bowels receive the introverted irritation, rapid and un- 
manageable diarrhoea or cholera, will probably ensue. This is no 



OF DENTITION. 143 

imaginary view of the evil consequences that may result from an 
improper meddling with eruptive affections of a scabby or humid 
character, about the head, during dentition. I have witnessed 
some very striking examples of this kind, in the course of my prac- 
tice. An instance occurred to me about eight months ago. Dur- 
ing the active progress of dentition, a scabby and discharging 
eruption occurred on the cheeks, forehead, and behind the ears. 
I directed simple means, merely with the view of moderating the 
irritation and keeping the parts clean, and urged the impropriety 
of applying any thing calculated to dry up or remove the disease. 
The mother nevertheless, could not content herself with seeing 
the infant's face in so disagreeable a state, and, of her own accord, 
used astringent washes and other means, to remove the affection. 
In about a week after these applications were used, I was again 
called to prescribe for the child. The eruption was now almost 
entirely removed; the little patient was feverish and extremely 
restless and fretful. Suitable remedies were resorted to, but in 
opposition to all my efforts, the disease rapidly increased, and ter- 
minated in fatal coma, paralysis, and convulsions. See the chap- 
ters on "Crustea Lactea n and on "Sore Ears,'' 1 for further directions 
on this subject. 

The application of blisters behind the ears, or on the back of 
the neck, is often of essential service in the diseases that arise 
from difficult dentition. When symptoms of cerebral irritation 
supervene — such as great fretfulness, flushing of the cheeks, a 
warm and dry skin, starting and restlessness during sleep, and un- 
usual sensibility of the eyes to the light, the timely application of 
blisters behind the ears, or on the back of the neck, may prevent 
the development of inflammation in the brain or its meninges, or 
obviate an attack of dangerous diarrhoea, convulsions, &c. &c. In 
violent and obstinate diarrhoea, from dentition, I have often de- 
rived unequivocal advantage from this practice. Whatever is cal- 
culated to diminish cerebral irritation, or to lessen the determina- 
tion of blood to the brain, may be usefully applied, in the sympa- 
thetic diseases of dentition; for, with the exception of eruptive af- 
fections, they are almost always dependent on, or at least connect- 
ed with and aggravated by, cerebral irritation. In the sudden 
convulsive affections, which are so apt to occur during dentition, 



144 OF DENTITION. 

immersing the feet and legs in warm water, and applying a cloth 
soaked with cold water to the head, is, in general, more certain 
and prompt in procuring relief than any other remedy we possess. 
The simultaneous application of cold to the head and warmth to 
the feet, has a powerful tendency to diminish sanguineous conges- 
tion and inordinate excitement in the brain. These two applica- 
tions should always go together when the brain is in an irritated 
and congested condition. The propriety of keeping the bowels 
in a loose state during dentition, has already been mentioned. 
When violent affections supervene, or when there are indications 
of the approach of serious sympathetic disorders from dentition, 
and diarrhoea does not attend, great benefit may frequently be 
obtained, from active purgatives. By stimulating the bowels in 
this way, and directing the circulation and excitement upon them? 
the brain will be relieved, and the diseases depending on its irri- 
tated condition either prevented or mitigated. 

When the gums become ulcerated, before the teeth are protru- 
ded, they should be lanced, and touched occasionally with a solu- 
tion of sulphate of copper, or of the nitrate of silver. Four grains 
of either of these articles, dissolved in ah ounce of water, and ap- 
plied with a dossil of lint, forms an excellent application in cases 
of this kind. A decoction of the root of coptis trifoliata, (golden 
thread), has frequently done much good in my hands, in ulcerated 
gums. 



DIABETES OF INFANTS. 145 



CHAPTER XI. 

OF THE DIABETES OF INFANTS. 

Diabetes is, probably, a much more frequent disease during 
infancy than is generally supposed. Since it was first noticed by 
Moreton, in his Phthisiologia, it has received but little attention, 
from writers on the diseases of children. Mr. Venables, however, 
in his recent work on diabetes, has contributed some interesting 
and valuable information on the diabetic affections of children; and 
it is from this source, principally, that the following observations 
are drawn. 

Infantile diabetes seldom occurs after the second year of age. 
Dr. Dewees states that "all the children he has seen affected with 
it, were under fifteen months old." It does not, however, seem 
apt to come on during lactation; for, according to the observations 
of Mr. Venables, its appearance previous to weaning is extremely 
uncommon. 

In the commencement of the disease, the child loses its usual 
playful and active disposition, and, although no obvious malady 
be discernible, it soon becomes dull, languid and fretful, with an 
uneasy and anxious expression of the countenance. In a short 
time, its flesh begins to waste; and as the emaciation gradually in- 
creases, the skin becomes dry, harsh, and so flabby, that "it seems, 
at length to hang loosely about the body." During the early stage 
of the disease, "the bowels are regular, and little or no deviation 
from the natural and healthy appearance of the alvine discharges 
is to be noticed." The tongue, too, exhibits a natural appearance, 
in the beginning, but in the advanced stage of the disease, it 
always becomes more or less conspicuously covered with a coat of 
white fur, or thick transparent mucus. After the disease has 
made considerable progress, the bowels begin to act irregularly, 
and the alvine discharges acquire an unnatural, and, generally, 
bilious appearance. The skin becomes uniformly dry and very 



146 DIABETES OF INFANTS. 

warm; and emaciation goes on with increasing rapidity. The 
pulse is at first somewhat accelerated, becoming small, quick, 
hard and wiry, as the disease advances in its course. The abdo- 
men, gradually becomes more and more distended, and tense, — a 
symptom which in connection with the progressive emaciation, 
"frequently leads to the supposition of mesenteric disease." In the 
advanced stage of the complaint, the brain generally becomes 
more or less affected. "Headach, vertigo, and temporary delir- 
ium occasionally attend, and when a fatal termination takes place, 
the patient usually dies comatose and sometimes apoplectic." A 
considerable degree of fever, generally prevails during the latter 
periods of the disease; and in cases of long continuance, anasarca, 
and even general dropsy have been known to occur. "The most 
remarkable occurrence, however, although it frequently escapes 
observation, is the inordinate discharge of urine. This discharge 
increases in quantity so gradually, that it is not usually noticed. 
By the time it has become more remarkable, great thirst prevails, 
and hence it is neglected or unnoticed, because parents and friends 
conceive an excessive discharge of urine and an excessive con- 
sumption of fluid as naturally associated." The qualities of the 
urine vary in different cases. In some instances the urine is per- 
fectly limpid, without any sedimentous matter, or deposit; in 
others "it is milky, or like a mixture of chalk and water." Occa- 
sionally the urine is transparent, and "of a pale straw color;" and 
Mr. Venables saw a case in which it was of a green color. It 
appears, frequently, to contain a considerable portion of coagula- 
ble serum; and when the proportion of the coagulable matter is 
great, and the urinary discharge very copious, "the emaciation 
is always rapid and extensive."* Mr. Venables does not mention 
the occurrence of a saccharine condition of the urine, in infantile 
diabetes. In the case related by Moreton, the urine was very per- 
ceptibly sweet: I have myself witnessed three very distinctly 
formed cases of infantile diabetes, in all of which, the urine, 
though extremely copious, was perfectly insipid. 

There is reason to believe, as is observed by Mr. Venables, that 

* A Practical Treatise on Diabetes; with Observations on the tabes diuretica,or Urinary 
Consumption, especially as it occurs in Children, &c. By R. Venables, M. B. &c. p. 5-16 



DIABETES OF INFANTS. 147 

many cases that have been regarded as instances of dropsy in the 
head, marasmus, and mesenteric disease, were in reality cases of 
diabetes. I am the more persuaded of the correctness of this ob- 
servation from the error which I committed myself, in this respect, 
in the first case of this kind I witnessed. The child appeared to 
me to be laboring under mesenteric disease, and after having 
treated the case as such, for three or four weeks, the mother casu- 
ally observed, that the little patient passed a great deal of urine. 
I now directed my attention to this circumstance, and soon satisfied 
myself that the quantity of urine discharged was truly excessive. 
In the course of twenty-four hours, three pints of urine were col- 
lected, and much was discharged at night, as well as during the 
day, that could not be collected. The urine was clear, and of a 
pale straw color, but I neglected to ascertain whether it contained 
any coagulable matter. The infant was but fifteen months old. 
Infantile diabetes is, indeed, very rarely recognized, in its incipi- 
ent, or early stage; "and when it has made considerable progress, 
it simulates so many other diseases, that the real character of the 
complaint is not developed till its history is either wholly lost, or 
so confounded with symptomatic or secondary affections, that it 
can no longer be unravelled." Too little attention is, in general, 
paid to the urinary secretion, in the diseases of children. In mal- 
adies of a protracted character, attended with emaciation, and a 
general irritative condition, the urine ought always to be carefully 
inspected. There can be no doubt that serious derangements of 
this secretion often occur in children, without being suspected. I 
was quite recently called into consultation, in the case of a child 
about eighteen months old. It appeared languid, and was much 
emaciated; its bowels were irregular, the stools slimy and mixed 
with green bile, and it was evidently harassed with constant thirst. 
In this case the urinary secretion, on proper inquiry, was found to 
be preternaturally copious. It could not indeed be regarded as an 
instance of diabetes; but the quantity of the discharge was such, 
that it could not fail to contribute materially to the exhaustion 
and emaciation of the little patient, and manifestly required par- 
ticular attention in the remedial management of the case. The 
urine in this patient contained a considerable portion of sedimen- 
tous matter of the phosphatic variety. From what I have obser- 



148 DIABETES OF INFANTS. 

ved in relation to the urinary affections of children, I am induced 
to think, that infantile diabetes is frequently attended with an ex- 
cess oflhe earthy phosphates in the urine. This state of the uri- 
nary secretion, says Prout, "frequently occurs in sickly children, 
in whom the functions of the digestive organs are deranged;" and 
it is well known, that where this condition of the urine prevails, 
"symptoms very analogous to those of diabetes are apt to super- 
vene." From the connection which is known to exist between an 
excess of urea in the urine, and the symptoms usually denominated 
diabetes insipidus, in adults, there can be no doubt that a similar 
state of the urine is sometimes present in the diabetic affections of 
infants. This disease may, moreover, be associated with an albu- 
minous or coagulable condition of the urine, since this state of the 
secretion is sometimes attended with profuse diuresis, at a more 
advanced age. These circumstances are worthy of notice; and 
when properly estimated, may aid considerably in instituting a 
proper course of treatment; for it cannot be doubted that these 
different conditions of the urine require corresponding modifica- 
tions of remedial management. 

Treatment. In the treatment of this affection, much will of 
course depend, on the character of the urinary secretion. In 
cases attended with a saccharine state of the urine, recourse must 
be had to those means which experience has ascertained to be 
most beneficial in diabetis mellitus. Instead of the usual farina- 
ceous or milk diet, the nourishment should consist principally of 
the lighter and more digestible kinds of animal food. If febrile 
symptoms attend, it may be beneficial to apply six or seven 
leeches to the lumbar regions. Mild aperients, and the occasional 
use of the warm bath, will be proper. Opiates are often deci- 
dedly beneficial in this affection — more especially in the form of 
Dover's powder. To a child between one and two years old, a 
grain of this anodyne mixture, with, or without three or four 
grains of powdered uva ursi may be given two or three times 
daily. In the diabetes of adults, Mr. Latham used opium and the 
carbonate of iron with decided advantage; Mr. Venable speaks 
very favorably of the effects of phosphate of iron, in this com- 
plaint. Magnesia, given in small and repeated doses, has proved 



DIABETES OF INFANTS. 149 

serviceable; and Richter mentions a case of diabetes, in a child, 
which yielded to a course of emetics. 

It is but very rarely, however, that the urine is sweet in the 
diabetic affections of infants. In the ordinary forms of the dis- 
ease, mild laxatives, in alternation with Dover's powders and uva 
ursi, will often procure relief. Small doses of the bi-carbonate 
of soda, in union with two or three grains of the carbonate of 
iron, may be resorted to with a prospect of advantage. When 
the urine deposits a whitish sediment, hyoscyamus, or lauda- 
num, with uva ursi will sometimes prove beneficial. In one of 
the cases referred to above, I prescribed a solution of the extract 
of hyoscyamus, in the proportion of one scruple to an ounce of 
water, in conjunction with infusion of uva ursi, with manifest ad- 
vantage. Five drops of the narcotic solution, with a teaspoonful 
of the uva ursi tea, were given three times daily. Dr. Dewees 
cured several cases by "keeping the bowels freely open, and put- 
ting a quantity of the spirits of turpentine upon the clothes of the 
chidren, so as to keep them in a terebinthinate atmosphere. I 
have seen much good done in a case of this disease, by a turpen- 
tine plaster laid over the region of the kidneys. When the dis- 
ease has advanced so far as to be attended with much intestinal 
disorder, and a tumid and tense state of the abdomen, consider- 
able benefit would probably be derived from the internal use of 
small doses of balsam copaiva, or spirits of turpentine, with an 
occasional mercurial laxative. In this aggravated state of the 
disease the diet should consist of the simplest and blandest farina- 
ceous preparations. Where the digestive powers are good, and there 
are no manifestations of intestinal irritation, beaf tea or weak 
chicken broth, mixed with the usual farinaceous nourishment, or 
a portion of milk, will generally prove most beneficial. The gums 
should always be attended to, and if they are swollen and the 
teeth are near protruding, they ought to be divided or scarified 
with a lancet. When the child is fretful, and evidently harassed 
by painful sensations about the head and gums, small blisters laid 
behind the ears will sometimes procure much relief, and aid ma- 
terially in removing the diabetic affection. In every variety of 
this disease, it is of much consequence to promote the action of 
the cutaneous emunctories. The warm bath, and frictions with 



150 OF THE ERYSIPELAS OF INFANTS. 

dry flannel, repeated at proper intervals, are very suitable reme- 
dies for this purpose. 



CHAPTER XII. 



OF THE ERYSIPELAS OF INFANTS. 

Infants are liable to a peculiar erysipelatous inflammation, of 
a very obstinate and dangerous character. It usually comes on 
within a few days after birth, and occurs but very rarely after the 
fourth or fifth week. Dr. Dewees mentions two cases, which 
came on at a much later period — one after the third and the 
other after the sixth month. I have witnessed but one instance 
of its occurrence after the eighth week, and not more than three 
after the third week. Richter states that children have been 
born with blotches of erysipelatous inflammation so far advanced 
as to exhibit vesications and spots of gangrene. I saw a fatal 
case, about ten years ago, which had come on within five or six 
hours after birth. 

The inflammation generally commences, on the lower parts of 
the body, particularly about the nates, groins, and umbilicus, in 
the form of a small red blotch, and gradually spreads, irregularly, 
over the abdomen and along the back and inside of the thighs. 
The inflamed part is firm and extremely painful to the touch, 
presenting a swollen, dark-red or purplish surface of irregular 
shape. Generally, towards the end of the first day, large but 
thinly scattered vesicles appear, having inflamed livid bases, tend- 
ing sometimes rapidly to sphacelus. In some instances vesication 
does not occur until the disease has continued for several days; 
in others, the vesicles make their appearance, soon after the in- 
flammation is established. Occasionally no vesication occurs 
throughout the whole course of the inflammation. When the in- 
flamed part vesicates early, the disease generally spreads verv 



OF THE ERYSIPELAS OF INFANTS. 151 

rapidly and soon acquires an extremely dangerous condition. 
The tendency to gangrene in infantile erysipelas is, indeed always 
very considerable, except, perhaps, in those mild cases, which re- 
main free from blistering — a form of the disease, however, which 
is unfortunately, not often met with. The disposition to sphacelus 
is particularly great, when the inflammation is seated on the ab- 
domen; when it affects the extremities, it is more apt to termin- 
ate in ulcerative suppuration of the subcutaneous cellular struc- 
ture, but this occurs also, frequently, on the body, particularly 
about the nates and loins. The pus formed is generally very 
thin, of a greyish color, and frequently somewhat acrid and sani- 
ous. It travels along through the meshes of the cellular mem- 
brane, under the skin and between the muscles, until this tissue 
(the cellular) is almost entirely destroyed in the affected part. 
Small portions of the skin, finally slough off, and give exit to the 
confined matter, which is, usually, mixed with flocculi and shreds 
of sphacellated cellular membrane. Symptoms of intestinal 
and hepatic disorder, are seldom wholly absent in infantile 
erysipelas. 

The discharges from the bowels are usually frequent, griping 
and of a grass-green color. In some cases, however, there is con- 
stipation, with colicky affections, and frequent ejections of acid 
fluid from the stomach. The whole surface of the body, often 
presents a slightly jaundiced appearance, and the urine is usually 
manifestly imbued with bilious matter. 

Great diversity occurs, in relation to the violence and duration 
of this malady. In some instances, the inflammation passes off, in 
two or three days, without any very unfavorable consequences. 
Cases of this mild character are however very rare. Sometimes, al- 
though the inflammation is not extensive, it successively invades 
almost every part of the body. In its erratic passage over the 
surface of the body, it sometimes travels on by a continuous exten- 
sion in one direction while the parts previously affected are freed 
from the inflammation. Occasionally, however, it leaps as it 
were, from one place to another, disappearing from the part it 
occupies, and reappearing speedily in some other and perhaps 
remote part of the body. In some instances the skin surrounding 
the inflammation, to the distance of nearly an inch from its mar- 



152 OF THE ERYSIPELAS OF INFANTS. 

gin, is peculiarly firm to the touch, and cannot be pinched up or 
moved over the subjacent parts, as maybe done in a healthy state 
of the body. 

Meckel, in examining the body of an infant that had died of 
this disease, found the umbilical vein, together with a considera- 
ble extent of the surrounding peritoneum strongly inflamed; and 
this fact, led him to believe, that inflammation of this vein, occa- 
sioned by rude management, in cutting and tying the umbilical 
cord, constituted the primary cause of this malady. Osiander 
gives an account of a fatal case, which commenced in the geni- 
tals of a male infant soon after birth. The inflammation spread 
itself rapidly over the whole abdomen. On dissection, he found 
the umbilical vein full of thick yellow pus, from the navel to the 
vena-porta, with other traces of inflammation in the adjacent 
parts. Inflammation of the umbilical vein, might, perhaps, ac- 
count for the occurrence of erysipelas in the parts surrounding the 
navel; but even where the umbilical vein is found to be inflamed 
on post mortem examination, the correctness of this pathology 
must be very doubtful, since it is impossible to say, whether, the 
inflammation of the vein was primary, or the result simply of an 
extension of the erysipelas, from the external surface along the 
vein. Nevertheless, the fact, that in a very large majority of in- 
stances, the disease comes on either before or soon after the ex- 
tremity of the cord is cast from the navel, leaving this part in a 
tender and irritable condition, together with the circumstance 
that the erysipelas almost always makes its first appearance on the 
lower parts of the body, seems to favor the idea, that this danger- 
ous affection is frequently in some way or other connected with 
umbilical irritation. In some peculiar states of the system, the 
slightest injury of the skin is apt to give rise to erysipelatous in- 
flammation in adults; and it is not improbable, that a similar pre- 
disposition, in co-operation with irritation about the umbilicus 
may be a common source of infantile erysipelas. It may be said 
that as this disease sometimes occurs long after all irritation about 
the umbilicus has passed off, this mode of accounting for its occur- 
rence cannot be correct. It certainly cannot be presumed, that 
all, or perhaps even a majority of the cases are produced in this 
way; yet it is by no means improbable, that in some instances, at 



OF THE ERYSIPELAS OF INFANTS. 153 

least, irritation about the navel, in conjunction with a peculiarly 
depraved or irritable condition of the system, constitutes the ex- 
citing cause of the disease. It is worthy of notice, that in those 
cases which occur at an advanced period, after the navel has ac- 
quired a perfectly firm and healthy condition, the inflammation 
almost always occurs en the extremities or about the head and 
shoulders. Irritation and functional disorder of the liver and ali- 
mentary canal has also been referred to as the primary source of 
infantile erysipelas. There can be no doubt, that derangement 
of the biliary and digestive functions frequently co-operate with 
other causes in the production of this malady. Symptoms of func- 
tional disorder of the liver, and digestive organs, are seldom 
wholly absent in this affection, and require especial attention in 
prescribing for its cure. We can, however, hardly ascribe much 
influence to hepatic and intestinal derangements as exciting 
causes of this affection, since functional disorders of the digestive 
and biliary organs are very common throughout the whole period of 
infancy, whilst infantile erysipelas occurs but seldom, and is, in a 
great measure, confined to the first three or four weeks after 
birth. This latter circumstance justifies the presumption, that 
there is something peculiar to this early stage of infancy, to which 
the principal agency in the causation of this malady must belong. 
The disordered state of the biliary and intestinal functions, is per- 
haps, in many instances, an effect rather than a cause of the mor- 
bid condition upon which the erysipelatous affection depends. Its 
unfavorable influence on the disease, however, cannot be doubted, 
and a principal part of the remedial treatment consists in restor- 
ing the healthy action of the liver and alimentary canal. Breath- 
ing an impure atmosphere, has a very decided tendency to favor 
the occurrence of this disease. It is on this account, that the dis- 
ease is so much more apt to occur in lying-in, and foundling hos- 
pitals, than in private habitations. Dr. Underwood says, that he 
rarely met with infantile erysipelas in private practice, but re- 
peatedly in lying-in Institutions. It has, indeed, often prevailed 
endemically, in crowded and ill-ventilated hospitals. 

It does not appear that infantile erysipelas differs in any essen- 
tial point from the erysipelas of adults. It occurs under all the 
modifications, as to its phenomena and progress, that it is known 



154 OF THE ERYSIPELAS OF INFANTS, 

to assume at a more advanced age. In some instances, though 
very rarely, it continues for fourteen or fifteen days, with but little 
vesication, and no cellular suppuration. In general, however, vesi- 
cles appear very early; and in such cases, the tendency to suppu- 
ration and gangrene, is usually very great. In the majority of in- 
stances, the cellular tissue about the inflamed part becomes much 
infiltrated with serum. When deep incisions are made into the 
affected parts after death, a large portion of thin fluid issues, and 
the skin exhibits a firmer and thicker structure than in the natural 
state. In the commencement, the febrile reaction is sometimes 
of a high inflammatory grade; but when vesication begins, it often 
speedily assumes a low and typhoid character, and in many cases, 
the tendency to sinking is manifest as soon as the inflammation is 
established. The approach of suppuration is alwaj's attended 
with an obvious failure of the vital energies; and the instances of 
recovery after this has taken place are extremely uncommon. 

Treatment. — Though, in the commencement, often associated 
Avith an active grade of febrile excitement, infantile erysipelas 
rarely admits of very decisive antiphlogistic measures. An ob- 
vious tendency to prostration often occurs almost as soon as the 
inflammation makes its appearance, the fever being of a typhoid 
character from the onset of the malady. Occasionally, however, 
the fever is of a high or synochal grade, and in cases of this kind 
direct depletion may be resorted to with much propriety. I have 
met with but one instance in which it appeared to me, decidedly 
proper to abstract blood. The infant was unusually robust; and 
the pulse and general appearance of the little patient, indicated 
a high degree of febrile reaction. The inflammation occupied 
the upper part of the right thigh, groin and illiac region, and had 
not vesicated at the end of the third day. After the use of some 
purgatives, I directed four leeches to be applied around the in- 
flamed part, and the result was unquivocally beneficial. If 
leeches can be procured, they ought always to be used, in pref- 
erence to venesection, at this early stage of infancy. It is 
proper to observe, that, when leeching is resorted to in this affec- 
tion, the leeches should always be applied to the sound skin, 
surrounding the inflammation. Leeching is most apt to prove 



OF THE ERYSIPELAS OF INFANTS. 155 

beneficial, where the erysipelatous inflammation is of an erythe- 
matous character — that is, superficial, with but little swelling and 
infiltration of the subjacent cellular tissue. "A trifling abstraction 
of blood, will be sufficient to effect every useful purpose, where 
this measure is indicated." It will very seldom be proper, to ap- 
ply more than four leeches of the ordinary size; and, in the ma- 
jority of such instances, two or three leeches will be quite suffi- 
cient. When the inflammation spreads rapidly, and is attended 
with vesication, the leeches should be applied to some remote 
part, as a general depletory measure, if the condition of the sys- 
tem indicates the propriety of bleeding. I am not disposed, how- 
ever, to urge the employment of bleeding, whether general or 
topical, in infantile erysipelas, for although it may doubtless do 
good in some cases, yet I am entirely satisfied, that an active an- 
tiphlogistic treatment is attended with much risk of irremediable 
injury, even in cases that seem to warrant its adoption. 

The milder antiphlogistic means- -more especially laxatives, 
and diaphoretics are almost always decidedly indicated in the 
early stage of the disease. From the constant and intimate sym- 
pathy which subsists between the skin, and the mucous membrane 
of the alimentary canal, there can be no doubt, that intestinal ir- 
ritation from acrid foeculent matter and morbid secretions must 
tend to support and aggravate the external erysipelatous inflam- 
mation. One of the first remedial measures, therefore, should be 
to evacuate the bowels freely. For this purpose, a grain of calo- 
mel, followed some hours after, by a teaspoonful of castor oil, 
generally answers very well. If difficulty occurs in procuring 
free evacuations, laxative enemata should be resorted to in con- 
junction with the use of internal purgatives. After the bowels 
have in the first place been well evacuated, they should be 
kept in a loose state, by small doses of calomel in combination 
with rhubarb, or with ipecacuanna. A mixture of calomel, ipe- 
cacuanna, and bi-carbonate of soda forms a most excellent aperi- 
ent in this disease. A powder consisting of a fourth of a grain of 
calomel, the same quantity of ipecacuanna and one grain of the bi- 
carbonate of soda, rubbed up with a few grains of white sugar, 
should be given every three or four hours, or at longer intervals, 
so as to procure three or four alvine discharges in the course of 



156 OF THE ERYSIPELAS OF INFANTS, 

about twenty-four hours. The ipecacuanna promotes the laxa- 
tive operation of the calomel, and tends to keep up the action of 
the cutaneous exhalents, whilst the soda counteracts the forma- 
tion of acid in the primas viae. Mr. Lawrence, recommends the 
use of a mixture of James's powder and calomel, and there can 
be no doubt of its being very well adapted for this purpose. One 
sixth of a grain of the former with a fourth of a grain of the latter 
may be given three or four times daily. Calomel can seldom be 
omitted with propriety in the treatment of the early stage of in- 
fantile erysipelas. The liver is, probably, always more or less 
disordered in this disease; and calomel is doubtless often benefi- 
cial, by its operation on the biliary organs, independent of its 
aperient effects on the bowels. The stools, generally, present 
a grass-green appearance: and I have seen an instance in which 
they were black and viscid, like meconial matter, for several days. 
It is necessary, however, to proceed with caution in the use of 
calomel at this early period of infancy. When given very freely, 
it is apt, at this tender age, to give rise to dangerous irritation of 
the stomach and intestinal canal. Throughout the whole course 
of infantile erysipelas our principal aim should be to restore the 
regular action of the liver, alimentary canal and of the skin. 
Should the small doses of calomel and ipecacuanna fail to keep 
up" the requisite action of the bowels, an occasional dose of castor 
oil, or of magnesia, should be used; and to promote the regular 
action of the cutaneous exhalents, warm or tepid bathing may be 
resorted to with a prospect of advantage. In the erysipelas of 
adults, attended with symptoms of biliary derangement, Desault, 
strongly recommends the use of emetics, and from a case which 
came under my notice, about eight years ago, in an infant nearly 
four weeks old, I am inclined to think, that the occasional use of 
emetic doses of ipecacuanna, would often prove serviceable in the 
early stage of infantile erysipelas. In the child referred to, pretty 
active vomiting was unintentionally excited by a dose of calomel 
and ipecacuanna on the third day of the disease; and the erysipe- 
latous affection almost immediately assumed a more favorable 
appearance. When the skin is very dry and warm, some benefit 
may be derived from the use of mild diaphoretics. From fifteen 



OF THE ERYSIPELAS OF INFANTS. 157 

to thirty drops of the following mixture* will usually answer 
very well for this purpose. 

Where the tendency to visication and gangrene, is obvious, or 
where the attending fever is of a low and typhoid character, 
tonics must be employed at the same time that the bowels are 
kept in a loose state by the aperients already mentioned. The 
necessity of resorting to the use of tonics, is especially urgent, 
when the inflammation is about terminating, or has already ter- 
minated in suppuration or gangrene. Experience has shown that 
the sulphate of quinine is decidedly the most valuable tonic we pos- 
sess in cases of this kind. To an infant within the first month 
the sixth of a grain of this article, may be given every two or 
three hours. It may be advantageously united with a suitable 
portion of the extract of hyoscyamus— a combination which I have 
found peculiarly beneficial in the typhoid erysipelas of adults. 
The tenth of a grain of this extract may be given to an infant, two 
or three times daily. Should diarrhoea occur after suppuration 
has taken place, it must be immediately checked. For this purpose 
minute doses of Dover's powder, in union with prepared chalk, 
is probably the most suitable remedy. The fourth of a grain of 
Dover's powder, with two or three grains of chalk, mixed with 
mucilage of gum arabic, should be given every three or four hours 
until the bowels are quiescent. One or two drops of laudanum, 
also, given at proper intervals, will often suffice for this purpose. 
To support the system, where there is a tendency to prostration, 
some writers speak very favorably of the employment of the car- 
bonate of ammonia. I have used it in conjunction with quinine, 
with manifest advantage in a case of infantile erysipelas. Ammo- 
nia may in general be given earlier, without risk of increasing the 
inflammation, in cases attended with considerable fe\er, than qui- 
nine. When the circumstances are such as to render it doubtful 
whether stimuli and tonics should be employed or not, the carbon- 
ate of ammonia ought to be selected, if it be concluded to resort 
to such remedies. The diaphoretic tendency of this article, renders 
it more eligible in diseases of a typhoid character, attended with 
local inflammation, than, perhaps, any other article of the kind 

* R. Spirit Minderiri Ji. Vin. Antimonii, gtt. xxv. Syrup Lemonis 3ii. M. ft. 



158 OF THE ERYSIPELAS OF INFANTS. 

we possess — more especially where the propriety of such reme- 
dies may be doubtful. One of my medical friends has informed 
that, he had in two instances of infantile erysipelas derived un- 
questionable benefit from the internal use of spirits of turpentine. 
He gave three drops of it, every four hours, to an infant about 
six weeks old. In the erysipelas of adults I have in several in- 
stances, prescribed the turpentine, and, as it appeared to me, 
with a very good effect. 

Various opinions have been expressed with regard to the propri- 
ety or usefulness of attempting to subdue or restrain the erysipela- 
tous inflammation by local applications. Bateman asserts, that ex- 
ternal applications, "are in general unnecessary if not prejudicial," 
in the early stages of the disease; and the same remark is made 
by some other writers of respectability. The weight of good tes- 
timony, however, is decidedly in favor of external applications to 
the affected part; and my own experience has convinced me, that 
very important advantages may often be obtained from a judicious 
management of this class of remedies. Cooling applications, such 
as cold water — lead-water and other soothing means, were for- 
merly much resorted to in the treatment of erysipelas. Experience 
however, has not sustained the character of such applications as in 
general suitable remedies in this variety of inflammation. There 
evidently exists a close analogy between erysipelatous inflamma- 
tion, and the inflammation caused by a scald or burn. In both, 
the inflamed capillaries appear to be in a debilitated and pas- 
sively distended condition, requiring applications of an exciting 
character. In the erysipelas of adults, blisters often produce 
highly beneficial effects, and by proper management they may 
doubtless be used with equal advantage in the erysipelas of in- 
fants. Dr. Dewees, seems to place considerable reliance on them 
in the treatment of this affection. I have not resorted to blister- 
ing in more than one case, and in this instance it had a very good 
effect. The blister should be large enough to extend beyond the 
inflamed part, so as to vesicate a portion of the surrounding sound 
skin. After the plaster is removed, the blisters should be opened, 
and the vesicated surface dressed in the usual way, or what I 
should prefer, with weak mercurial ointment. When the erysip- 
elas is seated on one of the extremities, a blister round the limb, 



OF THE ERYSIPELAS OF INFANTS. 159 

on the sound skin, will frequently arrest its progress in that direc- 
tion. Blistering is most apt to prove useful, when the febrile ex- 
citement is moderate, the tongue moist, and the skin somewhat 
hot and tense. 

Of late years, the mercurial ointment has been a good deed 
employed in erysipelatous inflammation; and Dr. Dewees speaks 
favorably of its use in the present variety of the disease. In 
one instance under my care, its effects were obviously beneficial; 
but in the last case I witnessed, it did no good whatever. It should 
be applied, by spreading it on pieces of linen, and laying them 
over the whole of the inflamed part. Dr. Dewees directs, it 
should be applied only to the inflamed margin, and a portion of 
the surrounding sound skin, after the vesicles have opened, and 
the part has become covered with a crust of concrete serum. A 
weak solution of corrosive sublimate, also, has been frequently 
employed in this country, as a local application in erysipelas, and 
I have, in some instances, known it to produce very excellent 
effects. Three grains of the sublimate to an ounce of water, 
forms a solution of proper strength for this purpose. Pieces of 
linen moistened with it, should be laid over the inflamed part, 
and renewed from time to time, as they become dry, until the 
inflammation assumes a pale color. The external use of the 
nitrate of silver, also, will occasionally procure decided benefit in 
this disease. I have more frequently succeeded in subduing ery- 
sipelatous inflammation with this application, than with any other 
remedy I have employed. The solution, in the proportion of five 
or six grains to an ounce of water, should be applied over the 
whole inflamed surface, by strips of linen, in the way just men- 
tioned. In employing this remedy, the persons about the patient 
should be informed, that it will give a black color to the skin; 
for without such premonition, the discoloration of the skin will be 
apt to be mistaken for mortification, and excite great apprehen- 
sion and anxiety of mind. 

A lotion composed of sugar of lead and sub-carbonate of ammo- 
nia — one drachm of each, and a pint of water, is highly recom- 
mended by Dr. Peart, as a local application in this disease. — 
Some of the English surgeons speak very favorably of an oint- 



160 OF THE ERYSIPELAS OF INFANTS. 

ment formed of equal parts of ceratum calamines, ceratum sapo- 
nis, and unguentum plumbi acetatis. 

The practice of making free incisions through the inflamed 
skin, and subjacent cellular and adipose structures, has recently 
been greatly extolled as a means for arresting the progress of 
phlegmonous erysipelas. Mr. Lawrence declares, that ' ; these 
incisions are followed, very quickly, and sometimes almost instan- 
taneously, by relief, and a cessation of the pain and tension; and 
a corresponding subsidence of the inflammation almost always 
ensues. In twenty-four hours, the redness has usually disap- 
peared, and the skin itself is found wrinkled from the diminution 
of the general inflammatory tension. The immediate relief, al- 
though very desirable to the patient, is, however, of less conse- 
quence than the decided influence of the practice in preventing 
the further progress of the disorder; and this important result has 
never failed to occur within my experience, when the case has 
been a proper one for the practice, and the state of the patient 
has admitted of its being fairly tried." The incisions ought to be 
made in the early stages of the complaint, with a view rather of 
preventing the ultimate consequences of the inflammation, by 
giving exit to the blood and extravasated serum, than of evacua- 
ting the puss and sloughed cellular membrane. " It is when 
the action is beginning, has commenced, or is at its acme; when 
the heat is burning, the thirst ardent, the tension great, the pulse 
active, the pain acute, and the texture engorged with blood, that 
incisions are most apt to prove beneficial." Mr. Lawrence re- 
commends one long incision, extending from one boundary to the 
other of the inflamed part. Mr. Hutchinson, on the contrary, 
thinks it better to make a number of smaller incisions — about an 
inch or an inch and a half in length, through the skin and 
subjacent cellular structure. Mr. Lawrence and others have 
restricted this practice to phlegmonous erysipelas; but it appears 
from the experience of Dr. Dill, that it may be extended with 
advantage to other modifications of this disease. 

I am not aware that this practice has ever been tried in the 
erysipelas of infants. It is not improbable, that it might be re- 
sorted to in many cases of this kind, with much advantage. In- 
fantile erysipelas often presents a well-marked phlegmonous char- 



OF THE ERYSIPELAS OF INFANTS. \Q\ 

acter; and in such cases, if the situation of the inflammation 
were favorable, I should be much disposed to try the effects of 
the practice. 

When suppuration has taken place, an opening should be made 
into the most depending part of the cavity, so as to give free exit 
to the purulent fluid and sloughed cellular structure. If the mat- 
ter is suffered to remain confined, it will make its way between 
the muscles and tendons, destroying the cellular tissue as it pro- 
ceeds, until the patient sinks under the general irritation and 
exhaustion which it produces. When a portion of the inflamed 
part becomes gangrenous, and offensive ulcers occur, the char- 
coal poultice is perhaps the best application. A poultice made 
of crumbs of bread, and a strong decoction of oak-bark, with a 
small portion of yest, forms a valuable application, where the 
ulcers assume a phagedenic character. 



162 SKINBOUND. 



CHAPTER XIII. 



INDURATION OF THE CELLULAR MEMBRANE AND SKIN. SKINBOUND. 

In private practice, this remarkable and very dangerous mal- 
ady is but seldom met with; but in lying-in and foundling hos- 
pitals, it is of very frequent occurrence. In the Hospice des Enfans 
Trouves, at Paris, 645 cases took place from 1808 to 1811;* and 
in 1826, there were 240 instances of it in the same institution.! 
On an average, one out of every twenty-five infants admitted into 
this hospital, become affected with this disease; and of those who 
are affected, not above twelve out of a hundred usually recover. 
In a vast majority of instances, the disease comes on within the 
first nine or ten days after birth. Mr. Billard states, that "nearly 
all the cases that occurred in 1826, in the abovenamed institu- 
tion, were in children of from one to eight days old, and some 
were affected from birth." Cases, nevertheless, sometimes occur 
at a much more advanced period of infancy. Mr. Andrews has 
recorded a remarkable instance, which occurred in a child eigh- 
teen months old; and I have seen a case in a child between the 
sixth and seventh month of age. 

In some respects, the disease is evidently closely allied to infan- 
tile erysipelas; and in others, it often manifests an obvious affinity to 
the convulsive affections. It usually commences on the lower 
parts of the body, particularly about the pubic region, and on the 
inner aspect of the thighs, and gradually spreads, becoming more 
or less conspicuous in different parts, until, in violent cases, the 
whole surface of the body becomes affected. The affected part 
is firm and incompressible to the touch, resembling the hardness 
and tension which occurs in phlegmasia dolens. The skin adheres 
so firmly to the indurated cellular tissue, that it cannot be pinched 

* Casper. Characteristic]* der Franzoesischen Medicine, p. 505. + Billard, Archives 
Generates de Medicine, Few 1827. 



SKINBOUND. !63 

up or moved even where it is usually most loose. In some in- 
stances, it presents a yellowish or wax-like appearance, and in 
others, it is of a pale red or purple color. Those parts that are 
reddish or purple, are generally considerably swollen; yet the 
swelling does not pit, although firmly pressed on with the finger. 
When the skin has a pale yellowish appearance, the tumeiac- 
tion is, in general, very slight; but the firmness and tenseness of 
the part is even greater than where there is lividness. The affected 
parts of the skin, whether pale or purple, are remarkably cold to 
the touch, and the surface generally is dry and harsh. The 
countenance is pale and contracted, and the little patient almost 
constantly " makes a peculiar kind of moaning noise," and appears 
to be unable to make a full inspiration and to cry out, from the 
restrained action of the thorax. Deglutition is generally very 
difficult, and sometimes wholly impossible. In seme cases, tetanic 
spasms supervene, in the latter stage of the disease; the jaws 
become locked, and the head and trunk are sometimes rigidly 
bent backwards. The pulse is usually small, irregular and rapid; 
and the bowels are almost always disordered — the discharges 
being sometimes of a bright green, and others of a whitish or clay- 
colored appearance. The urine is generally freely secreted, 
although, in some instances, the reverse takes place. 

Mr. Billard asserts, that there are two distinct varieties of this 
disease. He considers one variety as depending wholly on the 
infiltration of coagulable serum into the cellular structure. Cases 
of this kind are characterized by considerable tumefaction of the 
affected parts, with a deep red or purplish color of the skin. The 
other variety, attended with a wax-like appearance of the skin, 
and but very little swelling, depends upon a hardening of the 
subcutaneous adipose substance without, and with but little serous 
infiltration into the cellular structure. The parts where the adi- 
pose hardening, and consequent tightness of the skin, are usually 
most conspicuous, are the cheeks, the thighs, the calves of the 
legs, and the back. On dissection, in cases of this kind, the 
adipose substance is found as firm and condensed as suet, and 
the skin contracted and firmly adherent to it. 

The variety of the disease which arises from serous infiltration, 
is, according to Mr. Billard's observations, "nothing else than true 



164 SKINBOUND. 

cedema, altogether of the same nature with that which occurs in 
adults, affected with disease of the heart, or great blood-vessels." 
The hardness of the skin, he thinks, "is entirely owing to its 
being much less loose in early infancy than at a maturer age, 
and consequently yielding less readily to the pressure of the extra- 
vasated fluid." In making incisions into the indurated part, an 
abundance of serous fluid flows from the cellular structure; and 
Mr. Billard affirms, that when this is done at an early stage of 
the disease, the skin soon loses all its hardness. 

Very little of a satisfactory character has been brought to light 
with regard to the exciting or remote cause of this formidable 
complaint. It has been ascribed to the influence of cold, soon 
after birth; but its endemic occurrence in certain hospitals, does 
not favor this opinion. It is evident from this fact, that foul or 
deteriorated air must have a considerable agency in the produc- 
tion of the disease. In private practice, it is most commonly 
met with among the poor, who live in crowded and filthy habita- 
tions. Children who are nourished with artificial food, appear to 
be much more liable to the disease, than those who are nourished 
at the breast. In the Foundling Hospital in Paris, there are 
always a number of fresh nurses; and it has been observed, that 
whenever there is a deficiency of wet nurses in the institution, and 
the children are chiefly or entirely confined to artificial nour- 
ishment, the disease is most common. These facts, in connec- 
tion with the circumstance, that the bowels are often much dis- 
ordered, before the occurrence of the external affection, would 
seem to indicate that intestinal irritation, in co-operation with 
that depraved and irritable state of the system, which is apt to 
arise from breathing a contaminated air, constitutes a principal 
source of this malady. The causes of this disease differ, proba- 
bly, very little from those which give rise to infantile erysipelas. 
This affection is often attended with a condition of the skin very 
analogous to erysipelas; and we frequently find erysipelatous 
inflammation associated with considerable induration of the sub- 
cutaneous cellular tissue, for some distance beyond the inflamed 
margin. It occurs sometimes in the progress of other diseases — 
particularly in protracted affections of the bowels, accompanied 
with biliary disorder. The case related by Mr. Andrew was 



SKINBOUND. 165 

preceded by a feverish and restless state, accompanied with diarr- 
hoea. The last case but one which I witnessed, was preceded 
for upwards of two weeks with loose and griping stools, a gen- 
eral irritated state of the system, and an obstinately dry skin. 
Hardening of the cellular structure and skin is frequently accom- 
panied by a jaundiced appearance of the surface. M. Billard 
states, that in the Parisian foundling institutions, " the most com- 
mon accompanying disease, is jaundice." 

On post mortem examination, the cellular tissue is generally 
found thickened, condensed, engorged with serum, and often 
of a dense, reddish, and granular appearance, " not unlike a 
portion of hepatized lung." In many cases, the adipose substance 
is peculiarly consolidated, with more or less infiltration into the 
cellular membrane. The lymphatic glands are frequently found 
indurated and enlarged, more especially those of the mesentery. 
Out of ninety cases examined by Mr. Billard, there were twenty 
that presented a decidedly morbid condition of the liver; and 
fifty, in which there was inflammation of the alimentary canal. 
In all the cases, there was " a very remarkable general conges- 
tion. The venous blood especially predominated in the different 
tissues." Mr. B. thinks that this congestion does not depend on 
mechanical obstruction in any point of the circulation, but is due 
to " a general superabundance of blood in the system, or a kind 
of congenital plethora." From the remarkable and unconquer- 
able dryness of the skin, there is evidently " some derangement 
of the capillary circulation ;" and this morbid inactivity of the 
cutaneous exhalents, in conjunction with a general plethoric and 
irritative condition of the system, constitutes, perhaps, the imme- 
diate cause of cellular infiltration and tension of the skin. 

Treatment. — Although an extremely dangerous affection, this 
singular malady is not so entirely beyond the control of reme- 
dial treatment as was formerly supposed. Out of 645 cases which 
occurred in the Hospice des Enfans trouv&s, from 1808 to 1811, 
there were 78 cured; and the proportion of recoveries has of late 
years been considerably greater. Mr. Billard thinks that the 
opinion respecting its fatality, has arisen, in a great degree, from 



166 SKINBOUND. 

the circumstance of its being very frequently associated with other 

diseases of a dangerous character. 

The aqueous vapor bath is decidedly the most valuable remedy 
that has hitherto been recommended for the cure of this affection. 
As soon as the disease makes its appearance, the infant ought 
to be subjected to the vapor bath; and this should be repeated 
every three or four hours, until the skin becomes moist and soft, 
and the tightness and hardness has disappeared. The heat of 
the vapor should not exceed 105°; the most comfortable and 
salutary temperature being from 98 to 100°. When the child 
is taken out of the bath, it should be wrapped up in warm and dry 
flannel, and laid in its bed. The simple application of warm flannel 
immediately to the skin, and frequently renewed, will sometimes 
bring on a gentle perspiration, and reduce the local oedema.* If no 
suitable apparatus for applying the vapor be at hand, the infant 
should be laid in its bed, and hot bricks wrapped up in wet pieces 
of flannel, placed a short distance from its body under the covers, 
supported by hoops or some other contrivance, so as to leave a 
free space for the accumulation of the vapor. Richter speaks 
very favorably of the effects of blisters in this complaint. When 
early applied to the affected parts, they may remove the sanguine- 
ous engorgement of the sub-cutaneous structures, and arrest the 
progress of the induration. The only instance of recovery which 
has occurred in my practice, was effected by the vapor bath, 
and blistering. The induration commenced on the anterior sur- 
face of the left thigh and groin. An epispastic was applied over 
the whole surface of the affected part, and suffered to lie about 
three hours, when it was substituted by a large emolient poultice. 
The tumor and hardness of the part were obviously diminished 
by the blistering, and they did not extend beyond the limits 
which they occupied when the blister was applied. As the liver 
and bowels are generally more or less disordered, minute doses 
of calomel, in union with ipecacuanna, as recommended in infan- 
tile erysipelas, may be employed with occasional advantage. — 
Some writers, indeed, look upon calomel as a remedy of indis- 

* In the foundling hospital at Florence, this disease is treated by the application of 
external heat, made by keeping the infant wrapped up in warm flannel, in conjunction 
with stimulating frictions. 



SKINBOUND. 167 

pensable importance; and there can be no doubt, that when the 
disease is attended with prominent disorder of the liver, its influ- 
ence will often be highly salutary. In those cases that are accom- 
panied by a jaundiced appearance of the skin, mercurials are 
especially indicated, and can never with propriety be wholly ne- 
glected. It appears to me not improbable, that free incisions 
through the skin and subjaceat cellular tissue would prove bene- 
ficial. The engorgement of the subcutaneous capillary vessels 
ought, perhaps, be removed in this way, and exit given to a 
portion of the infiltrated serum — effects which could hardly fail 
doing good, in certain cases of this complaint. The tepid or warm 
bath, which has been much recommended by some German wri- 
ters, appears to be much less beneficial than dry warmth, or the 
vapor bath; and it is even asserted, that warm bathing has fre- 
quently proved injurious. 



168 OF CORYZA. 



CHAPTER XIV. 



OF THE CORYZA OF INFANTS. 



Tins disease was first described by Underwood, under the 
name of coryza maligna — an affection, which, he says, " is not 
only far more severe, but of a very different character," from the 
complaint which passes under the name of the " snuffles." Dr. 
Denman, who, afterwards, published a more ample and circum- 
stantial account of this malady, speaks of it as " a new and very 
peculiar affection." It appears to occur but very seldom; and it 
is doubtful whether it has ever been observed in this country. I 
have met with one case, which appeared, in many respects, to 
accord with the descriptions given of this complaint by Under- 
wood and Denman; but it was, probably, nothing more than an 
aggravated case of the common coryza from cold. It was at first 
supposed, that it never occurred in infants over a month old; but 
Underwood states, that he has seen instances of it at a much 
more advanced age. 

The disease is characterised by a purulent discharge from the 
nose, acquiring in some instances, a sanious character, attended 
with complete stoppage of the nostrils, and great difficulty of 
breathing, especially during sleep. The infant appears pale and 
languid, and a singular purple streak encircles the margin of the 
eyelids, which Mr. Denman was disposed to regard as pathogno- 
mic. There is usually " a general fulness about the throat and 
neck externally," which comes on soon after the purulent dis- 
charge from the nose commences. After these symptoms have 
continued for some days, the tonsils and fauces present a tumified 
and dark-red appearance, " with ash-colored specks upon them," 
terminating, in some cases, in extensive ulcerations. As the dis- 
ease advances, the infant declines rapidly in strength; and the 
breathing, often, becomes so difficult, that an attendant "is re 



OF CORYZA. 169 

quired to watch the little patient, in order to open its mouth as 
often as it may be requisite to prevent suffocation." The disease 
usually continues two or three weeks, and when it does not ter- 
minate in death, is very apt to leave a state of chronic indisposi- 
tion, attended with much disorder of the alimentary canal. 

This appears to be a very dangerous affection. Denman states 
that of eight cases which he witnessed in the course of about a 
year, two, only, recovered. Dr. Underwood, however, observes 
that the cause of its frequent fatality, when it was first noticed, 
arose, rather from the true nature of the disease having been im- 
perfectly understood, than from any positive difficulty in control- 
ling its progress by remedial management. The disease appears 
to consist in a peculiar inflammatory affection of the mucous 
membrane of the nasal cavities, extending backwards to the fau- 
ces and, in some instances, descending into the stomach and bowels, 
giving rise to painful and exhausting diarrhoea. The alvine 
evacuations are frequently of a peculiar bluish or green color, par- 
ticularly after the employment of repeated purges. Mr. Hunter 
and Mr. Home examined the body of an infant that had died of 
this malady; but the only morbid appearance they discovered 
was a dark-red and highly injected state of the lining membrane 
of the nose. 

Treatment. — According to the experience of Dr. Denman, the 
employment of laxatives so as to keep the bowels freely open, 
and remove from them the acrid matter which descends into the 
stomach from the nose, constitutes " the grand means of cure." 
If this be not constantly attended to, painful and rapidly wasting 
diarrhoea almost invariably arises from the irritating fluid that is 
continually passing into the stomach. The free use of mucil- 
aginous drinks, also, will be beneficial in this respect. Harsh 
purgatives, however, are highly improper, as they could scarcely 
fail to produce almost as much irritation as the irritating cause 
which they are intended to remove. " One or more teaspoonfuls 
of castor oil should be given, every day, so as to procure three or 
four motions daily. It is remarkable, that even weak infants en- 
dure purging better under this complaint than under any other, 
unless it be the fever caused by painful dentition" (Underwood). 



170 OF CORYZA. 

The employment of mild clysters also will be proper, — more espe- 
cially, when the lower part of the rectum becomes considerably 
irritated. Dr. Denman states, that he often derived much benefit 
from small doses of opium, or the syrup of white poppies. There 
can be no doubt of the great propriety of using narcotics in this 
affection, for it is evidently attended with an irritative state of 
the general system, without a very active inflammatory condi- 
tion, or a tendency to high febrile excitement. Dover's powders, 
given in small doses, would, probably, have a very beneficial 
effect, by allaying the morbid irritability and disposing to general 
diaphoresis. When the disease continues for several weeks, and 
" the infant becomes pallid and very feeble, a recourse to the de- 
coction of oak bark has at once removed the snuffling, and given 
vigor to the infant in the course of a few days." The sulphate of 
quinine would, doubtless, be a useful remedy in cases attended 
with much debility and exhaustion. The disease sometimes as- 
sumes a chronic character, and continues four or five weeks, and 
occasionally for several months. Such cases are apt to be attended 
with occasional attacks of spasmodic respiration, " as if the infant 
were dying." This symptom, " as well as the snuffling often 
recurs some time after the child seemed to be cured:" and even 
the purulent discharge from the nose, may recur from time to 
time, after the disease appears to have been wholly subdued. In 
eases of this kind, Underwood, besides purging, recommends fo- 
menting applications to the bridge of the nose; and "afterwards 
to apply some aromatic liniment." The application of a few 
leeches to the root of the nose would, perhaps, be beneficial in 
the early as well as in this advanced stage of the disease. There 
appears to be some risk in using vesicatories in this affection; 
for Underwood observes, that " the parts on which blisters had 
been laid in the beginning, and which had been apparently heal- 
ed, often sphacelated towards the conclusion." 



APHTHjE of infants. 171 



CHAPTER XIV. 



OF THE APHTHA OF INFANTS. THRUSH. 

This is one of the most common diseases of infancy. It is 
characterised by a peculiar eruption of minute pustules, giving 
rise to a whitish incrustation of the tongue, and lining membrane 
of the mouth and fauces. The aphthae sometimes make their 
appearance without any previous symptoms of general indisposi- 
tion, or disorder of the alimentary canal. Much more frequently, 
however, symptoms of disorder of the stomach and bowels, associ- 
ated with manifest languor and drowsiness, precede the occurrence 
of the aphthous affection. The aphthae usually appear, first, on 
the inner surface of the angle of the lips, and about the tip of the 
tongue, in the form of white specks, resembling small flakes of co- 
agulated milk. From these parts, the eruption spreads, more or 
less rapidly, until, in some instances, a continuous aphthous crust 
is formed, over the whole surface of the tongue, mouth and fauces. 
In many cases, however, the eruption is much less extensively dif- 
fused, the aphthae occurring only on the tongue, and central parts 
of the cheeks; and we occasionally find them scattered in small 
patches with intervening spaces, over the lining membrane of the 
mouth and surface of the tongue. In these mild cases the infant 
seldom experiences any particular uneasiness or disturbance from 
the local aphthous affection; but when the eruption is extensive, 
it rarely fails to give rise to more or less suffering and disorder in 
the system. In cases of this kind, there is, generally, much thirst, 
restlessness, languor, acid and flatulent eructations, loose, green, 
and griping stools, drowsiness, pain, and difficulty of sucking, and 
a copious flow of saliva and mucus from the mouth. The skin is 
usually dry and harsh; and, in the severer instances of the disease, 
a slight degree of febrile irritation often occurs. The stomach 
and bowels are almost always prominently disordered in such 



172 APHTHAE of infants. 

cases. The infant is apt to vomit after taking any thing into its 
stomach, and the milk is generally thrown up, in the form of firm 
coagula. Profuse watery diarrhoea frequently ensues, and the lit- 
tle patient is greatly harassed by sour and offensive eructations, 
griping and colic pains, and tenesmus from the extremely sensible 
and excoriated condition of the margin of the anus. Under these 
symptoms emaciation and loss of strength go on rapidly; the 
child's countenance becomes pale, sunken, and expressive of much 
suffering and uneasiness. The difficulty of swallowing increases, 
and at last sometimes becomes altogether impossible. The abdo- 
men is always sore to the touch, in cases of this violent character, 
and frequently much distended and tympanitic. If the disease is 
not arrested, the infant, at length, dies in convulsions, or in a state 
of stupor and insensibility, resembling the last stage of hydroce- 
phalus, or from exhaustion. 

In mild forms of the disease, the aphthous eruption continues 
of a white or yellowish color throughout; but in severe cases it 
soon acquires a dark brownish color, and instead of being soft and 
humid, as in the ordinary instances, it often becomes dry and harsh, 
as the disease advances. It is generally believed, that the aphtha? 
frequently extend from the mouth, throughout the whole tract of 
the alimentary canal. Dr. Dewees is disposed to doubt whether 
such an extension of the eruption does ever occur. He is inclined 
to believe that it never passes lower down than to the cardiac ex- 
tremity of the oesophagus. In examining the body of an infant 
that had died from aphtha?, he found "the whole tract of the oeso- 
phagus literally blocked up with an aphthous incrustation to the 
valve of the cardia, where it suddenly stopped. Not a trace of 
aphtha? was discovered below this place." I have myself had an 
opportunity of examining the body of an infant, that had died of 
this disease. In this case, the aphtha? were very distinct through- 
out the whole course of the oesophagus. The stomach and bow- 
els presented nothing that bore any resemblance to this eruption; 
but there were decided marks of inflammation in the mucous mem- 
brane of the small intestines, with a vast number of minute super- 
ficial ulcerations, and larger patches of softening of this tissue, 
throughout the colon, and lower part of the rectum. The mucous 
membrane of the alimentary canal, doubtless, always becomes 



APHTHA OF INFANTS. 173 

more or less diseased in the severer forms of this malady. It is 
probable, however, that the minute pustules, which give rise to 
the aphthous incrustation on the more dense mucous membrane 
of the mouth and oesophagus, terminate speedily in superficial 
abrasion, or ulceration, in the delicate mucous tissue of the stom- 
ach and bowels. In the case which I examined, these minute ul- 
cerative points were very obvious in several portions of the large 
intestines. The excoriation of the anus, which is generally re- 
garded as an evidence that the aphthous affection has passed 
throughout the whole extent of the alimentary canal, arises, per- 
haps, solely from the irritation produced by the acrid discharges 
from the bowels. Tenderness and excoriation of the anus is by 
no means an uncommon consequence of acrid diarrhceal discharges. 

The duration of this affection is very various. In slight cases, 
the aphthae disappear in a few days, without any unpleasant con- 
sequences. In some instances, the aphthous eruption continues 
for several weeks, without becoming very severe, or causing any 
material deviations from health. Sometimes, the aphthous crust 
falls off, and is soon succeeded by another one; and these separa- 
tions and renewals of the eruption, may occur three or four times, 
in the course of the malady. " The oftener the crust is renewed, 
the worse it becomes, for each new eruption is usually thicker and 
less white, than the preceding one." When the crust falls off, it 
exposes a smooth, red and slightly excoriated surface. The cav- 
ity of the mouth is always unnaturally hot, and the affected parts 
are, in general, very sensible and painful when pressed on or 
touched. 

Infantile aphthas very rarely occurs a second time in the same 
infant — at least as an idiopathic affection. It may, indeed, recur 
frequently, at every stage of life, as a symptomatic effect of other 
diseases — particularly in the advanced stages of protracted mala- 
dies attended with irritation of the alimentary canal. But it is ex- 
tremely doubtful, whether these secondary or symptomatic affec- 
tions are identical in their character, with the usual aphthoe of 
infancy. 

Some writers affirm that the disease is very rarely, if ever, at- 
tended with fever; whilst others declare that the occurrence of 
febrile irritation in this complaint, is very common. Hecker di- 



174 APHTHA of infants. 

vides the aphthae of infants into three varieties. His second vari- 
ety, which he affirms is very common in Germany, is always at- 
tended with decided febrile symptoms; and he thinks that the dis- 
ease is closely allied in its nature, to the exanthematous fevers. 
It commences with manifestations of lassitude, restlessness, drow- 
siness, and much thirst. The child seizes the nipple eagerly, but 
immediately leaves it again, and cries, as if the effort of sucking 
gave it much pain. The cavity of the mouth is hot, dry, red, and 
very sensible. The child is apt to vomit; frequent watery, green, 
and painful alvine discharges occur, and the urine becomes scanty, 
the pulse is accelerated, and the skin preternaturally warm and 
dry; the voice becomes rough and slightly hoarse; and finally, 
after these symptoms have run on for three or four days, the aph- 
thous eruption makes its appearance. Dr. Hecker asserts, that 
when the disease occurs epidemically, it almost always assumes 
this febrile character, assuming, in some degree, the regular pro- 
gress of an exanthematous fever. According to my own observa- 
tions, the ordinary simple cases of the disease are invariably with- 
out the slightest manifestations of fever. When the eruption is 
extensive, however, and there is much disorder of the alimentary 
canal, slight febrile symptoms are certainly often developed. I am 
at present attending an infant severely affected with this com- 
plaint. The aphthous crust extends over the whole surface of the 
tongue, mouth, and fauces, and from the manifest pain on swal- 
lowing, probably passes down to a considerable distance into the 
oesophagus. This child is in a decidedly febrile condition ; although 
before the aphthous eruption appeared, its general health seemed 
to be good. The febrile symptoms that occasionally attend the 
ordinary forms of the disease, depend, probably, chiefly on the 
inflammatory irritation which is apt to occur in the alimentary 
canal, and are wholly accidental. 

In hospitals, this disease sometimes assumes a highly dangerous 
character. In the French foundling institutions, it is said to carry 
off a great many infants. In these malignant cases, the aphthous 
crust soon becomes thick and of a dark brown color. When it 
falls off, it leaves a number of yellowish-brown ulcers, of a corrod- 
ing character. The diarrhoeal discharges are green, and extreme- 
ly acrid, and the vital powers sink very rapidly. Is the aphtb.33 



APHTHAE OF INFANTS. 175 

or thrush of infants a symptomatic or an idiopathic affection? 
The general opinion appears to be, that it is altogether symptom- 
atic — occurring as an accidental consequence of gastro-intestinal 
disorder. Dr. Dewees, expresses himself in a very ambiguous, or 
rather contradictory manner, on this point. In the beginning of 
his chapter on this disease, he says, " that this affection is one of a 
symptomatic kind — rarely, perhaps never, idiopathic;" yet in a 
subsequent paragraph, he observes, " the opinion so commonly 
credited, of its being a symptomatic affection, is very questiona- 
ble;" and then goes onto give a number of " facts," which he 
says have "lately" led him "to question the sympathetic origin 
of aphthae." Nevertheless, the very next paragraph commences 
in these words: " This symptomatic affection is not confined to 
early infancy." The fact is, the arguments which led the Doctor 
to doubt the correctness of his opinion, that the disease is purely 
symptomatic, would have convinced him of its entire erroneous- 
ness, if he had not viewed them through the medium of a contrary 
sentiment long and thoroughly entertained. It takes a powerful 
battery of " facts " to knock down an opinion that has become firm 
by age. For my own part, I am well satisfied that the disease, 
as it occurs in early infancy, is of a peculiar and strictly idiopathic 
character; although an aphthous affection of the mouth may, and 
often does, occur at every stage of life, as a symptomatic or sec- 
ondary phenomenon of other forms of disease, or morbid condi- 
tions of the digestive organs. We see this often, in the last stage 
of phthisis pulmonalis, and in nearly all protracted diseases of a 
febrile and exhausting character, as they approach a fatal termin- 
ation. It is, also, frequently observed in children, as an attendant 
on other maladies; particularly such as are attended with disorder 
and inflammatory irritation of the alimentary canal. 

If the aphthae of infants were a purely sympathetic affection, 
depending on disorder or irritation of the alimentary canal, it 
could of course never take place without the previous occurrence 
of gastro-intestinal disorder. Cases, however, do occur, in which 
no obvious signs of derangement of the digestive or intestinal 
functions can be noticed. Dr. Dewees states that he has seen 
two instances, in which the alimentary canal "was in the most 
perfect order; and I have, certainly, witnessed several cases which 



176 APHTHA OF INFANTS. 

were entirely free from any manifestations of disorder of the stom- 
ach and bowels. It may be presumed, too, that were the disease 
symptomatic in its origin, derangement of the alimentary canal 
would be much more frequently associated with aphthae, than it 
is known to be. At every period of life, from early infancy to ad- 
vanced age, disorder and irritation of the stomach and bowels oc- 
cur very frequently, and pass through every grade of violence, 
without giving rise to aphthae. Mere disorder or irritation of the 
alimentary canal, is very rarely productive of aphthous eruptions 
in the mouth, unless it be connected with a chronic form of febrile 
irritation, and general exhaustion. In infantile aphthae, however, 
the child often appears to enjoy good health, up to the time when 
the aphthae make their appearance; and in mild instances, there 
is frequently no material indisposition during the continuance of 
the aphthous eruption. This, I believe, never occurs in the aph- 
thous affections which take place at a more advanced age. These 
cases are always, unequivocally, connected with serious general 
maladies, and seldom occur, until the diseases of which they are 
symptomatic phenomena, have acquired a highly dangerous, if not 
a necessarily fatal degree of violence. The circumstance, how- 
ever, which seems most clearly to shew that infantile aphthae is a 
peculiar idiopathic affection, is the fact, that infants who have 
passed through the disease, very seldom become affected with it a 
second time, although the stomach and bowels may become re- 
peatedly disordered, and remain so, during the subsequent period 
of infancy and childhood. We often see infants affected with 
aphthae, previous to the third month, with very little disturbance 
in the alimentary canal; yet they will not become affected with 
it again, although they may afterwards be repeatedly and long 
harassed by disorder of the stomach and bowels. The circum- 
stance, too, that this affection is almost wholly confined to the age 
of infancy, would appear to indicate that there is an essential pe- 
culiarity in its character and mode of origin. If it were an acci- 
dental sympathetic phenomena of gastro-intestinal irritation, with- 
out any specific peculiarity in its nature, we should expect to meet 
with it at every period of life, instead of seeing its occurrence 
almost entirely restricted to a particular stage of childhood. The 
occasional appearance of this infantile malady in an epidemic 



APHTHLE OF INFANTS. 177 

manner, is also manifestly opposed to the idea of its being a purely 
symptomatic affection. In some foundling hospitals in Europe, it 
has frequently prevailed endemically for a season; an occurrence 
which could not, with the slightest plausibility, be ascribed to 
any disorder of a symptomatic character. In mild cases, the 
aphthous affection may often be speedily removed, by local ap- 
plications to the mouth, alone; and occasionally, even severe in- 
stances will yield to remedies of this kind, without the employ- 
ment of any thing for improving the general health, or correcting 
the morbid condition of the alimentary canal (Dewees.) From 
a view of the foregoing considerations, the idiopathic character 
of infantile aphthae can, I think, hardly be doubted. It is very 
manifest, however, that disorder of the stomach and bowels, con- 
tributes very materially to the production of this disease, either 
by creating a predisposition to it, or by exciting the latent ten- 
dency in the infantile system to its occurrence. 

Feeble and sickly children scarcely ever escape this disease; 
and they are much more apt to become severely affected with it 
than those who are of a robust and healthy habit of body. What- 
ever is capable of disordering the stomach and bowels, may be 
regarded as an exciting cause of the disease. Unwholesome and 
indigestible nourishment, and over-distention of the stomach, 
during the early stage of infancy, almost inevitably lead to the 
occurrence of aphthae. Bad and old milk, and thick farinacious 
preparations sweetened with brown sugar or molasses, are espe- 
cially apt to give rise to the disease. Inattention to keeping the 
infant's mouth clean by occasionally washing out the sordes with 
a soft piece of linen and fresh water, and particularly the nau- 
seous practice of permitting the child to suck portions of food 
tied up in a piece of cloth in the form of a nipple, contributes 
greatly to the production of the aphthous eruption. Breathing 
an impure and deteriorated air, also, appears to have a decided 
tendency to favor the occurrence of this malady. Children who 
are kept in crowded and ill-ventilated apartments, or who are 
suffered to sleep much under the bed-clothes, are especially lia- 
ble to become affected with it. The occasional great prevalency 
and fatality of the disease in foundling institutions, doubtless 
arises, in part, from this cause. When improper nourishment co- 

2 A 



178 APHTHA OF INFANTS. 

operates with foul air, the disease is apt to acquire a highly dan- 
gerous character. It has been supposed that the apthae of infants 
is often propagated by a specific contagious virus. Dr. Good is 
of this opinion, and refers, as some of the German writers do, to 
the excoriations, which frequently occur on the nurse's nipples, 
when the nursling is affected with aphthae, ll.eie is evidently 
i very acrid and irritating fluid discharged frcm the minute pus- 
tular eruption, which occasions the aphthous crust; and when the 
nipples are tender, they can scarcely fail to become more or less 
inflamed and excoriated, by the impressions of this acrimonious 
secretion. In hospitals, where several infants often suckle the 
same nurse in succession, it is not improbable that the occurrence 
of the disease may sometimes be favored in this way. The natu- 
ral predisposition to the disease, appears to be much stronger 
in some families than in others. In my own, consisting of eight 
children, this affection has never occurred, although all of them 
suffered from the usual stomach and bowel complaints of infancy. 

Treatment. — As the alimentary canal is almost invariably more 
or less deranged in the aphthae of infants, a principal object in 
the treatment must, of course, be to remedy the disordered con- 
dition of the stomach and bowels. In general, the ejections from 
the stomach are sour, and the alvine evacuations of a grass-green 
color. When this is the case, magnesia, with small portions of 
rhubarb and powdered valerian, will generally prove very bene- 
ficial. I have more frequently derived decided advantage from 
this mixture, than from any other mode of administering magne- 
sia. From three to four grains of magnesia, with two grains of 
rhubarb, and one grain of powdered valerian, should be given 
every two or three hours, until the bowels are freely evacuated. 
If there is much general irritability and restlessness, the tepid bath, 
followed by a drop or two of laudanum, should be employed after 
the magnesia has operated on the bowels. The mucous mem- 
brane of the intestines is apt to become highly irritated in severe 
cases, after the aphthous eruption has continued for some days. 
The alvine evacuations, in such instances, become very frequent, 
small, watery, with occasional streaks of blood, and painful; and 
the margin of the anus red and extremely sensible. In cases of 



aphtha of infants. 179 

this kind, a large emolient poultice over the abdomen, in con- 
junction with the internal use of minute portions of Dover's pow- 
der, with a solution of gum arabic as drink, has frequently proved 
highly beneficial in my practice. Dr. Dewees speaks very fa- 
vorably of the oil of butter, when the bowels are much irritated. 
" The oil of butter is prepared by putting a lump of perfectly 
sweet butter into a cup, and pouring on it a quantity of boiling 
water, and agitating it well with a teaspoon, that it may be de- 
prived of its salt — the oil is then skimmed off, as it is wanted. 
A teaspoonful may be given three or four times daily." I have 
used this oil in a few instances, but it did not appear to answer 
quite so well as a pretty thick solution of gum arabic, given in 
teaspoonful doses at short intervals. Magnesia, and o.her purga- 
tive remedies, seldom fail to do harm in cases attended with much 
intestinal irritation. In a few instances of extremely obstinate 
aphthag, accompanied with frequent irritating stools, and an exco- 
riated state of the anus, I have procured marked benefit from a 
very weak solution of the nitrate of silver. Incompatible as the 
article may seem to be with a highly irritated state of the mucous 
membrane of the bowels, it nevertheless often exerts a very 
soothing effect on this tissue, when under peculiar forms of irrita- 
tion. I have given about half a teaspoonful of a solution of a 
grain of this article to two ounces of water, every four hours, to 
infants between two and six months old, with unequivocal advan- 
tage, and without the slightest aggravation of the sufferings of the 
patient. In cases attended with much acid in the stomach, 
without a great deal of intestinal irritation, or diarrhoea, lime- 
water, with a weak infusion of peruvian bark, usually produces 
an excellent effect. When the acidity of the prima? via? is accom- 
panied with free diarrhoea, without any symptoms of inflammatory 
irritation of the bowels, prepared chalk, in union with minute 
portions of Dover's powder, generally proves decidedly useful. 
From four to six grains of the chalk, with the fourth of a grain 
of Dover's powder should be given every two or three hours, until 
the diarrhoea is checked, and the discharges assume a more natu- 
ral color. I have given powdered borax internally in aggrava- 
ted cases of infantile aphtha:, with very decided advantage. There 
is uothing ia this article that forbids its internal empioymeat. 



180 APHTHAE of infants. 

The Germans use it frequently in this way; and I have, myself, 
often resorted to it, in bovel complaints, with evident benefit. 
In the present disease, I am persuaded that it may be given inter- 
nally, with peculiar advantage, in the severer forms of the com- 
plaint accompanied with frequent irritating diarrhceal discharges. 
I have been in the habit of applying large fomenting poultices 
over the abdomen, in cases of an aggravated character; and I am 
satisfied that this application is capable of doing much good. 
When the disease runs on for a long time, and the little patient 
becomes much exhausted, mild tonics and stimulants should be 
employed to support the system. Weak wine whey — infusion 
of cinchona, or a weak solution of quinine, in moderate portions, 
may be resorted to for this purpose. 

If the infant is not weaned, it should receive no other nour- 
ishment than its mother's milk. If it is nursed with artificial 
nourishment, nothing but the most bland alimentary prepara- 
tions ought to be used. A solution of gum arabic, cow's-milk 
and water, barley-water and weak chicken or beef tea, form 
proper articles of food for this purpose. If the child is nourished 
at the breast, an attention to dietetic regulations on the part of 
the mother, is believed to be of considerable importance. She 
ought to avoid the ordinary articles of vegetable food, as they 
favor the generation of acid in the prima? viae. All kinds of 
spirituous and fermented drinks, too, have an unfavorable ten- 
dency, and ought to be particularly avoided. The more digesti- 
ble meats, soft-boiled eggs, rice, stale bread or crackers, fresh 
butter, with weak tea or coffee, constitute appropriate articles of 
nourishment in cases of this kind. 

Local applications are generally highly serviceable, and in 
slight cases, are, by themselves, often sufficient to remove the 
disease in a few days. Borax is a familiar remedy with nurses 
and mothers, as well as with the profession, for this purpose; 
and it is doubtless the most valuable article we possess, as a local 
remedy in this affection. It may be used in the form of powder 
or solution. If the former is employed, two or three grains of it, 
mixed with a small portion of pulverized loaf-sugar, must be 
thrown into the mouth every two or three hours. If the solution 
be used, a drachm of the borax should be dissolved in two ounces 



APHTHiE OF INFANTS. JQ1 

of water. This maybe applied to the mouth, with a soft linen 
rag, tied to the extremity of a pliable piece of whalebone or wood, 
or with a soft feather. The powder, however, is the most con- 
venient mode of applying this remedy. In making local applicat 
tions, care should be taken that the aphthous crust be not rudely 
rubbed off. This always causes much pain to the infant; and 
is calculated to increase the inflammation and keep up the dis- 
ease. The practice of forcibly rubbing off the aphthous erup- 
tion with a piece of linen, on the point of a finger — so common 
with ignorant nurses, is extremely reprehensible. Nothing can 
be gained by this rude and painful treatment, and much mischief 
may readily result from it to the little patient. When rubbed 
off in this way, the crust is, almost always, soon renewed in 
an aggravated form, and the irritation in the mouth is generally 
much increased. So long as the aphthous incrustration remains 
white, the borax may be deemed the most efficient local remedy. 
When the eruption assumes a yellow or brown color, however, 
it frequently fails to do any decided good. In such cases, Dr. 
Dewees generally employs "the armenian bole, in fine powder, 
with loaf sugar," small portions of which mixture, are, from time 
to time, thrown into the mouth, as directed above for the borax. 
"Should this fail," he says, "to give pretty speedy relief, and 
particularly if the mouth be very red, livid or ulcerated, we then 
have recourse to a weak decoction of bark." A half ounce of 
powdered bark, boiled about thirty minutes, in half a pint of 
water, forms a proper decoction for this purpose. "About the 
third of a teaspoonful of this is put into the child's mouth, every 
hour or two." I do not doubt that these remedies are capable 
of procuring much relief in cases of this kind. Instead of the 
armenian bole, however, I prefer using a weak solution of the 
nitrate of silver, in the proportion of a grain to an ounce of 
water, and applying it with a soft piece of linen fixed to the end of 
a thin piece of whalebone. Nothing need be apprehended from the 
introduction of a small portion of this fluid into the stomach. 
On the contrary, its effects on the morbid condition of the mu- 
cous membrane of the alimentary canal, are often decidedly 
salutary in cases of this kind. A decoction of oak-bark, par- 



1S2 APHPHiE OF INFANTS. 

ticularly where there is much diarrhoea, will sometimes produce 
a very good effect as a local remedy. 

As the acrid alvine discharges are very apt to inflame and 
excoriate the parts about the anus, constant attention should be 
paid to keeping these parts as clean as possible. The nates should 
be frequently washed with tepid milk and water, or with flax-seed 
tea; and after they are carefully dried, fresh lard should be applied 
over the irritated parts, to afford them some degree of protec- 
tion against the impressions of the acrid evacuations. When 
the inflammation and sensibility of these parts become very se- 
vere, they should be occasionally, washed with a weak solution 
of sugar of lead, mixed with proper portions of a watery solu- 
tion of opium. 



ULCERATION OF THE MOUTH. 183 



CHAPTER XV. 



ULCERATION OF THE MOUTH. 



Children are liable to an ulcerative affection of the mouth, 
which is evidently, entirely distinct in its origin and character, 
from the ordinary aphthous eruption. It consists, in a number of 
small ash-colored and excavated ulcerations, with elevated edges, 
situated about the froenum, and along the inferior margin of the 
tongue, the gums, and on the cheeks. The ulcers usually begin 
in the form of small, red, slightly elevated and painful points. 
At first they are superficial, and occasionally even somewhat 
raised above the surrounding skin; but in the course of a day 
or two, the edges rise up, and the ulcerated surface becomes con- 
siderably excavated. When the ulcers appear on the upper sur- 
face of the tongue, which, however, occurs but seldom, they are 
generally quite superficial, appearing more like excoriations than 
actual ulcerations. 

The disease commences with slight symptoms of febrile irrita- 
tion. The child manifests some degree of lassitude and restless- 
ness. The skin becomes warmer and dryer than natural, the 
pulse somewhat accelerated and sharp, the bowels usually cos- 
tive; there is generally much thirst; the tongue is coated with a 
thin white fur, over which, a thick layer of transparent slime is 
spread, and there is a constant profuse discharge of saliva and mu- 
cus from the mouth. The mind and body are peculiarly irrita- 
ble. The child is generally exceedingly fretful and uneasy, "espe- 
cially when it is about to take the nipple, which it frequently seizes, 
and then lets go, with a whining cry as if in pain." The febrile 
symptoms usually continue for two or three days, and often much 
longer, before the ulceration commences. After the ulcers are 
formed, however, and the slavering is profuse, the fever generally 
subsides. In some instances the ulceration of the gums and 



184 ULCERATION OF THE MOUTH, 

cheeks becomes very extensive. In cases of this kind, a slow, ex- 
hausting fever is apt to occur, which generally renders the man- 
agement of the complaint very difficult. I have met with two 
cases of this disease, in which the gums were almost entirely de- 
stroyed. In one of them, the whole inferior maxilary bone was 
at length deadened and separated, and was removed by Dr. 
McLellan. These aggravated instances of the complaint, are fortu- 
nately not common, and the disease is, in general, easily managed 
when early attended to. 

This affection is almost always associated with weak or disor- 
dered digestive functions, and a bloated and torpid state of the 
bowels. Children whose breath is offensive, with a variable ap- 
petite, and a tumid and hard state of the abdomen, are most lia- 
ble to this complaint. The irritation of dentition, doubtless, con- 
tributes, in some degree, to the production of the disease; but 
the primary source of the complaint, appears to be located in the 
alimentary canal. 

Treatment. — Purgatives are highly useful remedies in this com- 
plaint. The bowels should be freely evacuated, though not with 
harsh or very active purges. A small dose of calomel, followed, 
in the course of four or five hours, by a suitable dose of castor oil, 
will answer this purpose very well. The oil without the calomel, 
or a proper dose of magnesia, should be repeated daily, until the 
febrile symptoms are subdued. Even where no fever is present, 
mild laxatives are highly useful, more especially, if the abdomen 
be full and somewhat tense. I have known much benefit de- 
rived, from the use of a few mild emetics in cases of this kind. 
When the breath is offensive, and there is a tendency to nausea 
and vomiting, the exhibition of an ipecacuanna vomit, will fre- 
quently do much good. In a case of a severe character, which I 
saw, about a year ago, I ordered five grains of ipecacuanna, with 
two grains of calomel. Active vomiting was induced, and three 
or four alvine evacuations followed. On the following morning, 
the child's mouth was evidently better; and it continued to im- 
prove rapidly. The tepid bath, and gestation in the open air, if 
the weather be mild, will often aid considerably in arresting the 
local ulcerative affection. After the operation of a purgative, 



ULCERATION OF THE MOUTH. 185 

the general irritability of the system should be allayed, by a few- 
drops of laudanum, or one or two grains of Dover's powder. In 
using calomel in this affection, great care ought to be taken, lest 
it affect the gums — an occurrence, which could hardly fail to im- 
part a dangerous character to the ulcerations. 

When the febrile irritation is subdued, much advantage maybe 
procured from local applications. A solution of the sulphate of 
copper, mixed with a portion of honey, will generally soon im- 
prove the appearance of the ulcers, and hasten their healing. Ten 
grains of the sulphate should be dissolved in about three teaspoon- 
fuls of water, to which four teaspoonfuls of honey must be added. 
This solution must be applied to the ulcers, once or twice daily, 
by means of a strong camel's hair pencil. Dr. Devvees advises 
the addition of two drachms of powdered bark, and a drachm of 
powdered gum arabic to this solution; but I have not found it to 
answer better, than the simple solution I have mentioned. Touch- 
ing the ulcers, with a solution of the nitrate of silver, also, is an 
excellent local remedy. In several very severe cases, 1 obtained 
more decided benefit from this application than from the sulphate 
of copper. In slight instances of the disease, a strong decoction 
of oak bark, with a small portion of alum dissolved in it will gen- 
erally suffice to arrest the progress of the ulcers, and dispose them 
to healing. I have derived evident benefit, in cases of this kind, 
from the internal use of small portions of powdered charcoal. 

The diet should be particularly attended to. If the child is 
still nourished at the breast, its mother's milk is doubtless the best 
nourishment. If it has been weaned, however, nothing but the 
simplest and mildest articles of food should be allowed. If, how- 
ever, the child has been previously, almost exclusively nourished 
by farinaceous aliment, it will in general be useful to change it, in 
part, for beef or chicken tea, or very light and simple broths. 
Solid food must on no account be allowed; more especially salted 
meats or fish. 

Dr. Underwood has described a variety of ulceration of the 
mouth, under the name of Aphtha gangrenosa, which appears to dif- 
fer materially from the preceding affection. It seldom oocurs in 
children under two years old, and has been but rarely noticed 
after the ninth year of age. It usually commences with a swollen 

2 B 



ISO ULCERATION OF THE MOUTH, 

spongy and dark-colored condition of the gums, attended by 
"great tenderness of the inside of the cheeks and mouth." In 
the course of a day or two, small dark-colored ulcers appear on 
"the gums, the inside of the lips and upon the tongue;" and oc- 
casionally, ulcers of the same appearance occur en the tonsils and 
uvula. "As the disease proceeds, the cheeks become slightly tu- 
mefied, and are very tender when touched; and there is often an 
unusual redness upon that portion of the skin which covers the 
lower jaw." The tongue is covered with a thick yellowish brown 
fur, becoming darker as the disease advances, and the teeth are 
apt to become covered with a black sordes. The breath be- 
comes extremely offensive after the ulceration has made some 
progress. There is usually a very copious flow of saliva from the 
mouth. There is from the commencement of the complaint con- 
siderable febrile irritation. The child becomes languid and fee- 
ble, the pulse small and quick, and the skin very warm and dry; 
the appetite is impaired, but the little patient ofen sleeps well, 
and at times appears cheerful and disposed to amuse itself with 
play. The disease may continue for a period of from two to five 
or six weeks. 

Dr. Dewees says that this variety of ulceration of the mouth, 
occurs only, when children are cutting teeth, particularly when a 
number of back teeth, are about making their appearance at the 
same time; and this accords entirely, with my own observations. 
It is a disease of the gums, arising from cutting the last of the first 
set of teeth — it therefore never attacks after this process (primary 
dentition) is completed: or at least not until the teeth of the 
second dentition are about to appear. The gums at first swell 
and become dark red and very tender. In the course of two or 
three days, "the parts of the gums immediately over the teeth 
about to be protruded give way by ulceration to a greater or less 
extent" (Dewees.) 

This disease, though of an alarming appearance, is by no 
means a dangerous affection. In children of a sickly and scor- 
butic habit of body, however, it sometimes becomes very trouble- 
some, and resists, for a long time, the usual remedial applications 
in diseases of this kind. The swollen parts of the gums ought to 
be divided down to the advancing teeth; and the child's mouth 



OF COLIC. 187 

frequently washed with a strong decoction of peruvian bark. I 
have used a solution of the chlorite of lime, with a most excellent 
effect in several severe instances of this affection. I dissolved a 
drachm of the chlorite in six ounces of water, and applied it with 
a soft piece of linen tied to the end of a probe. A decoction of 
oak bark too, with or without a small portion of alum forms an 
excellent application. 



CHAPTER XVI. 



OF COLIC. 



There are very few infants who do not suffer more or less from 
colic pains. In many instances, indeed, they are so slight and 
transient, that they require no particular remedial attention. 
Very frequently, however, they become extremely harassing, re- 
curring often, and with great severity, during the first five or six 
months of infancy. In some cases, these painful attacks occur 
several times daily, at uncertain intervals; and in others, they 
come on at regular periods, assuming a distinctly periodical 
progress. 

In slight cases of colic pains, the infant suddenly becomes very 
fretful, draws up its legs towards the abdomen, and whines or 
cries for a few moments and then resumes its usual quiet condi- 
tion. After a very short interval of rest, another attack, of the 
same kind occurs, and again soon subsides; and thus, it will go 
on, with alternate spells of crying and quietude, until a volume of 
wind breaks from the stomach or bowels, or a thin foecal dis- 
charge takes place, when entire relief ensues. In many cases, 
however, these manifestations of suffering are much more vehe- 
ment and distressing. There is excessive, long-continued and un- 
appeasable screaming, forcible drawing up of the legs, or violent 
kicking, flushing of the face, and various writhings of the body, 



188 OF COLIC. 

with a distended, tense and tympanitic state of the abdomen. In 
the majority of instances, these attacks are associated with habit- 
ual symptoms of indigestion and disorder of the bowels — such as 
acid eructations, flatulency and diarrhoea. The stools are fre- 
quently of a grass-green color, or slimy, and occasionally mixed 
with portions of imperfectly digested food. In some cases, how- 
ever, the alvine discharges are neither too frequent nor of an un- 
natural appearance, although the infant almost daily experiences 
severe paroxysms of colic. The breath often has a peculiarly 
acid smell, and when vomiting occurs, which, however, is not 
often the case, the milk, if the child is nourished at the breast, is 
thrown off in dense coagulated masses. When the colic pains 
come on frequently, and are attended with prominent symptoms 
of indigestion and diarrhoea, the general health of the infant al- 
most always suffers obvious derangement. The child becomes 
pale, feeble, and fretful, and does not thrive. Sometimes, how- 
ever, the appetite remains good, and although the child suffers 
frequent and very severe attacks during a period of two or three 
months, yet no inroads appear to be made on its general health, and 
it goes on thriving, as if it were in every respect perfectly healthy. 
This is most apt to occur in those instances, where the paroxysms 
of colic recur at regular intervals, or in a periodical manner. 
This form of the complaint, is seldom connected with any decided 
manifestations of indigestion; and instead of being attended with 
loose and griping stools, it is very generally accompanied by con- 
stipation or slowness in the action of the bowels. Dr. Dewees 
states, that the paroxysms, usually, occur between four and six 
o'clock in the afternoon; but in this respect, I have not noticed 
any particular uniformity in the cases that have come under my 
own observation. I have known the attack to occur, regularly 
at a particular period in the forenoon; and I have recently pre- 
scribed for a case in which the paroxysms, uniformly came on 
between one and two o'clock every night. 

There evidently exists a very material difference between these 
periodical cases, and the ordinary irregular form of the complaint. 
The latter appear to depend on a dyspeptic condition of the ali- 
mentary canal, and are manifestly greatly under the influence of 
diet and other causes capable of producing weakness or irritation 



OF COLIC. 1S9 

of the digestive organs. The immediate cause of the colic pains, 
in the majority of cases, appears to consist in violent flatulent 
distention and irritation of some portion of the bowels. That 
this is the case seems very obvious from the drum-like distention 
of the abdomen which usually occurs during the paroxysm, and 
from the relief which almost always follows the free discharge of 
wind from the bowels. The foundation for this painful affection is 
frequently laid during the first two or three days after birth. The 
extremely reprehensible practice of filling the infant's stomach 
with artificial food immediately after birth, before nature furnishes 
the appropriate nourishment, is, I am persuaded, a very com- 
mon source of this distressing complaint. The child's stomach is 
thus often, in the very beginning of life, thrown into a state of 
irritation and feebleness — so that even the congenial nutriment 
afforded by the maternal breasts, will pass into the bowels in an 
imperfectly digested state, and give rise to acid and flatulent disten- 
tion of the intestines. The exhibition of active purgatives, for the 
removal of the meconium, also, is well calculated to originate this 
complaint. After the digestive organs have once been brought 
into a state of irritation or functional derangement, the mildest 
and most appropriate nourishment, will not be properly digested; 
and this state of things must almost necessarily continue until the 
digestive energies have acquired a considerable degree of devel- 
opment; for the acid and flatus which are generated in conse- 
quence of the weakened condition of the stomach tend continual- 
ly to keep up the deranged state of the digestive functions. Thus 
when the delicate stomach of the new-born infant is overloaded 
with any of the usual alimentary preparations, it can scarcely es- 
cape being, in some degree, weakened and irritated. The very 
first nourishment which the child afterwards draws from its mother'? 
breast, will, probably, not be duly digested. Acid and wind 
will, therefore, be generated. These morbid products become 
additional causes of irritation and disorder of the digestive organs; 
and thus the complaint, generating as it were its own cause, may 
go on, for many months, however mild and fitting the nourishment 
may be. I know from repeated experience, that infants who re- 
ceive no aliment, or only small portions of suitable nutrient fluids, 
until the appropriate nourishment is supplied by the maternal 



190 OF COLIC. 

breasts, will, in general, be much less liable to colic and griping 
pains, during the first two or three months of infancy, than such 
as are gorged with food, in the usual way, soon after birth. When 
the digestive organs are thus early disordered, the colic pains 
usually commence within three or four days after birth. The 
stools become frequent, green, watery, or curdled, and very pain- 
ful, and in most cases, aphthae supervene, before the end of the 
second week. In general, errors in diet, constitute the ordinary 
source of the colic, and griping in infants. Overdistention of the sto- 
mach, especially with artificial food; or administering nourishment 
at such short intervals that the stomach is constantly kept in a 
state of repletion and exercise, is particularly apt to give rise to these 
harassing complaints. Even the most appropriate articles of food, 
will not prevent the occurrence of colic and griping, if they are 
very frequently and superabundantly administered, so as to deprive 
the digestive organs of the requisite and regular intervals of rest. 
Not unfrequently, very painful disturbance of the alimentary 
canal, arises from a bad state of the mother's or nurse's milk. 
Mental disturbance in the nurse sometimes exerts the most extra- 
ordinary influence in this respect, by the changes which it causes 
in her milk. A few years ago, I met with a very striking instance 
of this kind. I was called to an infant about five months old, 
extremely harassed with colic pains. Most violent and pro- 
tracted paroxysms of screaming and agitation occurred, three or 
four times daily. Its bowels were disordered, and frequent ejec- 
tions of acid, fluid mixed with coagula of milk, took place from the 
stomach. The child was nourished exclusively at its mother's 
breast. I was told that these attacks first came on, about two 
weeks before I saw the little patient, and soon after the mother 
had unexpectedly heard of the sudden death of her husband at 
sea. Previous to this distressing occurrence, the infant appeared 
to be perfectly healthy. I advised immediate weaning, and the 
use of two parts of cow's milk with one part of warm water, for its 
nourishment. In less than twenty-four hours after the child was 
put on the exclusive use of this food, it was almost entirely freed 
from its painful attacks; and in a few days more, appeared 
to be as well as it was, previous to the first accession of the 
complaint. The children of nervous, fretful, and ill-tempered 



OF COLIC. 191 

women arc much more liable to colic and other forms of gastro- 
intestinal disorder, than those of placid and equanimous mothers. 
Protracted grief, sorrow, or despondency in the nurse, often gives 
rise to very severe and continued colic pains in the suckling, which 
nothing but weaning or a change of the nurse is capable of 
preventing. 

Even physical pain in the nurse, when long-continued and ha- 
rassing — such as tooth-ach and neuralgia, may occasion very ob- 
stinate and severe disorder of the alimentary canal in the nursling. 
Dr. Dewecs relates a very curious instance of this kind. In the 
second week after birth, the child began to experience moderate 
attacks of colic; which gradually increased, in violence and fre- 
quency, until they became extremely severe and protracted. No 
relief could be obtained, except from laudanum, given "in large 
and constantly increasing doses." The fluid thrown from the sto- 
mach was sour; and the alvine evacuations were griping, thin, 
and often green. There was much emaciation. "In this situation 
did things continue, until the child was five months old, by which 
time it was (without a figure) nothing but skin and bone." In 
one of his visits the Doctor noticed the mother applying her hand 
very suddenly to her face and pressing it firmly. On being ask- 
ed the cause of her doing so, she stated that she had been for a 
long time much tormented with tooth-ach. The Doctor advised her 
to have the tooth immediately extracted. "This was accordingly 
done; and from that day the child began to recover, and in a short 
time was perfectly restored to health." 

Inattention to proper dietetic regulations, and consequent disor- 
der of the digestive functions, on the part of the mother or nurse, 
may also give rise to such alterations in the milk, as will occasion 
colic pains and griping in the infant. Under the head of wean- 
ing, several other circumstances, in relation to the mother have al- 
ready been mentioned, as sources of more or less serious disturb- 
ance in the stomach and bowels of infants. Of these a deficiency 
in the quantity of milk furnished by the breasts is a very common 
indirect cause of this painful affection in infants. To supply 
this deficiency, artificial nourishment must, of course, be resorted 
to: and in doing so, the child's stomach is apt to be overloaded 
with inappropriate articles of food. 



192 OF COLIC. 

Colic pains and griping may also proceed from the influence of 
cold — particularly from inattention to proper changes of the 
child's wet and cold linen, and from insufficient clothing and 
warmth about the abdomen and inferior extremities. 

It has already been observed above, that the periodical form 
of this complaint, appears to differ very materially both inits char- 
acter and mode of origin, from the ordinary cases of irregular flat- 
ulent colic. It is seldom associated with a dyspeptic condition of 
the digestive organs; and the beneficial influence of dietetic regu- 
lations, is certainly much less obvious in cases of this kind, than in 
the usual instances of the complaint; nor are those remedies which 
are generally relied on for preventing the generation of acid 
and wind in the primae viae, or for removing them, capable of pro- 
curing any decided advantage in these periodical cases. These 
attacks continue to recur regularly, for several months; their re- 
currence usually ceasing spontaneously, "as soon as the child 
reaches the age of three months." Br. Dewees thinks that cases 
of this kind, depend, probably, "upon some constitutional pecu- 
liarity, over which we have but a temporary control. 1 ' It appears 
to me likely that they do not differ from the gastralgia of adults 
— a form of neuralgic affection., which frequently assumes a peri- 
odical character, and which, like the present complaint, can sel- 
dom be materially influenced by the ordinary remedies for colic 
and griping pains. The attack in cases of this kind, generally 
comes on suddenly, and after having continued with occasional 
transient remissions for an indefinite period, varying from a few 
minutes to one or even two hours, it ceases as abruptly as it came 
on. From a close attention to several instances of this form of the 
complaint, I have been led to suspect that the pain, in such ca- 
ses, is generally seated exclusively in the stomach. The pain is 
not aggravated by taking food or drink into the stomach; and in 
one instance, which came under my notice, the sufferings were 
almost always obviously mitigated, by administering a few 
teaspoonfuls of thin arrow root, barley water, or of a mixture of 
milk and water. During the attack there is usually a good deal 
of flatulent noise in the abdomen, attended with epigastric disten- 
tion, and eructations of air, which, however, possess neither acidi- 
ty nor fetor. The digestion is nearly always good, and sometimes 



OF COLIC. 193 

even more rapid than in a perfectly healthy condition of the sto- 
mach and bowels. 

The colic of infants, as has already been observed, is by no means 
a dangerous, though always an extremely distressing affection. 
Nevertheless when the flatulent distention becomes very great, it 
may so weaken the muscular coat of a portion of the intestines, 
as to give rise, ultimately, to habitual costiveness of a very trouble- 
some and unmanageable character. In some cases a highly irri- 
tated or sub-inflammatory condition of the mucous membrane of 
the bowels is excited in the progress of the disease, giving rise to 
painful and exhausting diarrhoea, a hard and tumid state of the 
abdomen, derangement of the digestive functions, and a general 
irritable and irritated condition of the sanguiferous and nervous 
systems. These consequences, however, rarely ensue, except 
where errors in diet are habitually committed, or where harsh and 
irritating purgatives and other medicines are frequently employed. 

Treatment. — In the ordinary cases of infantile colic, associated 
with derangement of the digestive functions, or with habitual acid- 
ity and flatulency of the primas via?, judicious dietetic regulations 
are all-important remedial measures, — without which the most 
appropriate remedies will, at most, procure but temporary pallia- 
tion. When there is reason for believing that the mother's milk 
is unwholesome, an effort should be made to ascertain the cause 
of its faulty condition, which may, perhaps consist in habitual im- 
proprieties in diet, or in some accidental and removeable disorder 
on the part of the mother. Should the first be the case, proper 
dietetic measures should be immediately adopted by the mother 
or nurse, and every thing that tends to promote the generation of 
acid in the alimentary canal carefully avoided. If, notwithstanding 
a judicious regulation of the mother's diet, the infant continues to be 
harassed with frequent attacks of colic, some advantage may oc- 
casionally be obtained by applying it to the breast at long inter- 
vals, and substituting small portions of suitable artificial nourish- 
ment — such as very thin arrow-root, barley water, or a mixture 
of equal parts of cow's milk and water. When the child has been 
partly nourished by artificial food, in consequence of a deficient 
secretion of milk, we may sometimes derive much benefit from a 

2 C 



194 OF COLIC. 

change of the artificial portion of nourishment. A striking in- 
stance of the advantage that may occasionally be obtained in this 
Way came under my observation a few weeks ago. The infant 
about two months old was almost constantly in a state of alarming 
torment. The mother did not furnish sufficient milk for its sustenance, 
and it was regularly fed with a mixture of equal parts of cow's 
milk and water. Arrow-root, barley-water, tapioca, and sago, in 
suitable preparations were successively tried, but without the least 
benefit. A mixture of weak chicken-tea and a very thin pre- 
paration of arrow-root, in the proportion of one part of the former 
to two parts of the latter, was finally resorted to. By the use of 
this nourishment, the complaint was soon very obviously mitiga- 
ted; and under the additional influence of small doses of magne- 
sia and powdered valerian, yielded almost entirely in the course of 
nine or ten days. As the error often consists more in the excess, 
than in the quality of the food, particular attention ought always 
to be paid to this point. 

Infants who are partly nourished by artificial food, are par- 
ticularly liable to be injured by over-feeding. I have repeat- 
edly known great benefit derived from a mere reduction of 
the quantity of nourishment habitually taken by the infant — and 
particularly by lengthening the intervals between the meals so as 
to avoid the injurious practice of taking fresh food into the sto- 
mach before that which was previously taken has been fully di- 
gested and passed into the intestines. There are but few cases of 
flatulent colic that may not, in some degree be benefited by a ju- 
dicious management of the diet. Frequently, however, the re- 
lief obtained from measures of this kind is but small, and recourse 
must be had to other means for correcting the disordered condi- 
tion of the stomach and bowels, and especially to temporary pal- 
liatives for mitigating the violence of the attacks. 

Magnesia by its antacid and purgative effects, is one of the 
most useful remedies we possess for the management of this com- 
plaint. When there is a prevailing tendency to generate acid in 
the primae viae, small doses of this article, given two or three 
times daily, almost always produce an obvious abatement in the 
frequency and violence of the attacks. I have generally given it 
in union with small portions of powdered valerian root, and when 



OF COLIC. 195 

the bowels are torpid, with the addition of a few grains of rhu- 
barb. Three grains of magnesia, with two grains of powdered 
valerian, may be given twice or thrice daily, until the acidity in 
the stomach is removed. If this do not keep up a sufficient ac- 
tion of the bowels, the proportion of magnesia should be occasion- 
ally, increased, or a few grains of rhubarb added to the powders. 
Valerian is an excellent auxiliary to the magnesia, in cases at- 
tended with weakness of the digestive powers. I have used a 
solution of the bi-carbonate of soda in an infusion of valerian root, 
with very obvious benefit, in cases attended with much acidity. 
Twenty grains of the bi-carbonate of soda may be dissolved in 
two ounces of valerian infusion,* to which two or three drachms 
of ginger syrup may be added. A teaspoonful of this solution 
may be given several times daily, to an infant of from one to three 
months old. With the view of invigorating the digestive organs, 
and thereby impeding the formation of acid and flatus in the ali- 
mentary canal, small doses of a very weak infusion of colomba or 
of quassia may be resorted to with a prospect of considerable ad- 
vantage, in cases associated with general feebleness and relaxa- 
tion and a dyspeptic condition of the stomach. When the com- 
plaint is accompanied by thin, green and acid diarrhoeal dis- 
charges, some advantage may be gained from the occasional ad- 
ministration of very small doses of calomel, either by itself or in 
union with minute portions of ipecacuanna. A frequent employ- 
ment of this article, however, — particularly when given in full 
doses, is by no means advisable. Some years ago, 1 administered, 
in several cases of this complaint attended with constant acidity, 
flatulency, and diarrhoea, a mixture composed of five grains of 
prepared chalk, three grains of the powdered root of simplo- 
carpus foetida (skunk cabbage) and two of rhubarb, every morning 
and evening for five or six days in succession, with unequivocal 
benefit. The difficulty of procuring the powdered skunk cabbage 
in our shops, has since that time, prevented me from giving it 
again; though I am inclined to believe, that it possesses very ex- 
cellent powers, both as a palliative, and as a means for invigorating 

* The infusion should be made by macerating one ounce of the valerian root in a pint 
of warm water, for about twenty-four hours. 



196 OF COLIC. 

the depressed digestive energies of the stomach. When costive- 
ness prevails, this article may be given in union with magnesia, 
in the way mentioned above, or with valerian. 

In cases attended with frequent watery, green, or curdled and 
sour stools, accompanied with violent griping, antimonial emetics 
are strongly recommended by Armstrong. When the abdomen 
is not tender to pressure, and the little patient is free from febrile 
irritation, an occasional emetic dose of antimonial wine, followed 
by suitable doses of Dover's powder, will sometimes do much good 
in such cases. An instance of the usefulness of this practice, 
came under my notice about six months ago. The infant, about 
five months old, was extremely harassed with frequent small di- 
arrhceal discharges of a watery and grass-green character; and 
each evacuation was preceded by excessively severe and protrac- 
ted griping, as was evident from the child's vehement and unap- 
peasable screaming. An antimonial vomit was given in the morn- 
ing, followed after its operation by a grain and a half of Dover's 
powder. The disease was manifestly mitigated by these reme- 
dies; and by repeating them three times in the course of about a 
week, and employing, afterwards, small doses of prepared chalk 
and Dover's powder, in conjunction with the occasional applica- 
tion of rubefacient embrocations to the abdomen, the bowels were 
brought to a pretty healthy condition, and the little patient freed 
of his sufferings. In general, however, emetics are not appropri- 
ate remedies in infantile colic, except in cases where the morbid 
excitement is concentrated on the large intestines, and the stom- 
ach is in a languid or inactive condition. As a mere palliative, 
an emetic dose of ipecacnanna, will sometimes procure considera- 
ble relief when administered during, or at the commencement of 
the paroxysm, by expelling the wind and thus removing the dis- 
tressing distentions of the stomach and duodenum. A repetition 
of emetics, however, could hardly fail, in the ordinary cases of the 
complaint, to disorder the digestive functions, and to favor the oc- 
currence of inflammatory irritation in the stomach and bowels. The 
application of a large warm poultice over the abdomen, having 
previously rubbed the skin with hartshorn liniment, or, with the 
common camphorated mixture, will often assist materially in sub- 
duing the complaint, when it is accompanied with much intestinal 



OF COLIC. 197 

irritation, manifested by frequent small, thin and acrid or very- 
foetid evacuations. 

As a temporary palliative for lessening the violence and dura- 
tion of the attacks, Dr. Dewees, relies chiefly on the following 
mixture,* — which, he asserts " rarely fails to give instant relief, 
and sometimes even effects an entire cure." Twenty drops of this 
mixture should be given when the child is in pain, "and if not 
relieved in half an hour, ten drops more are to be administered." 
I have found this remedy, to procure prompt relief in some in- 
stances, but it has not been so uniformly beneficial, in my hands 
as the following preparation. Dissolve one drachm of camphor 
in an ounce of sulphuric asther. Take thirty drops of the solu- 
tion, twenty grains of magnesia, six drops of laudanum, and mix 
them together with an ounce of fennel-seed tea. Of this mixture 
a teaspoonful may be given, to an infant from two to six weeks 
old; and if sufficient relief be not obtained in half an hour, about 
half a teaspoonful more should be administered. I have fre- 
quently procured prompt relief by administering two or three 
drops of the simple ethereal solution of camphor, in a teaspoonful 
of sweetened water, and I am satisfied that we have not a more 
efficient palliative, for relieving the distressing pains attending 
this complaint. When remedies of this kind must be frequently 
employed, camphor is, in some respects preferable to opium, un- 
less diarrhoea and much intestinal irritation be present, in which 
case opiates in some shape or other can hardly be entirely dis- 
pensed with. In cases associated with diarrhoea and griping, the 
camphor may be advantageously given in union with laudanum. 
Two drops of the solution of camphor with half a drop of lauda- 
num may be given three or four times in the course of a day, 
when the pains are violent and of protracted duration. 

Gentle frictions with dry flannel or with the bare hand over the 
epigastric and umbilical regions, sometimes aids considerably in 
procuring the expulsion of the confined flatus. The introduction 
into the rectum, of a soap suppository during the colic attack, 
frequently produces copious discharges of wind and fasces, with 
great relief to the little sufferer. When costiveness prevails, lax- 

* R. Magnes. calcinat. Bi. Tinct. assafoetidae gtt. lx. Tinct. opii. gtt. xx. Aq. 
fontan. gi. M. 



198 OF COLIC. 

ative enemata, with the addition of twenty or thirty drops of 
tincture of assafoetida, are appropriate and often very efficient 
means of temporary relief. 

In the periodical form of the disease, dietetic regulations rarely 
afford any decided advantage. The diet should nevertheless be 
carefully attended to; for there can be no question as to the injuri- 
ous tendency of errors in this respect. The abovenamed pallia- 
tives may be resorted to with temporary benefit; but the relief 
obtained by remedies of this kind, is seldom so prompt and con- 
siderable in the present as in the common irregular form of the 
complaint. When employed at all, they ought to be given, "the 
instant the paroxysm is about to commence;" for when the colic 
is once fully developed, it very rarely yields in any obvious de- 
gree, to remedies of this character. The only article that I have 
found, capable of occasionally producing a decidedly favorable 
effect, is a few drops of the spirits of turpentine in a teaspoonful 
of good sweet oil, or milk. In some instances I have known this 
remedy to effect a speedy subsidence of the pains in this variety 
of the disease. From three to six drops of the turpentine may 
be given to a child of from one to three months old, and the dose 
may be repeated in the course of an hour without the least risk 
of injury. Viewing it as a strictly periodical complaint, Dr. 
Dewees has administered a decoction of the bark during the in- 
tervals of the attacks, and, as he informs us, "with the happiest 
effect in several instances." Formerly I employed the prussiate 
of iron in several cases of this kind; and in one instance, the ef- 
fects of this remedy were surprisingly beneficial. To an infant 
between one and three months old, a half a grain of this article 
may be given every three or four hours during the intervals of 
the paroxysms. In the successful case just referred to, this pre- 
paration of iron was given in union with powdered valerian. 
The infant was about two months old. A violent attack of colic 
occurred about six o'clock, every evening, and generally con- 
tinued for nearly an hour. The child had been affected with the 
complaint for upwards of three weeks before I saw it. After the 
bowels were freely evacuated by a dose of a few drops of syrup 
of rhubarb, I prescribed half a grain of the prussiate of iron with 
three grains of powdered valerian root to be taken every three 



OF COLIC. 199 

hours during the intermission. The first paroxysm after these 
powders were taken, was perhaps, as severe as any of the pre- 
ceding ones. The medicine was, however, continued, during the 
next intermission; and now, the attacks gradually subsided in vio- 
lence and duration, until, at the end of eight or ten days, the 
child was almost entirely freed of the complaint. I have, since 
this case, employed the same combination in another instance; 
but the effects, though not without obvious advantage, were by 
no means so promptly and decidedly beneficial as in the former 
instance. As the bowels are generally torpid in these cases, mild 
laxatives, must be used from time to time, to keep up the requi- 
site alvine evacuations. Active purging, however, is not only 
useless, but often decidedly injurious — a fact which I have, in 
several instances, seen strikingly verified. It would, I think, in 
general be better to procure the necessary evacuations by laxa- 
tive enemata, than by aperients taken into the stomach. If the 
latter be preferred, fresh cold-pressed castor oil, and syrup of rhu- 
barb, are the most appropriate. 

The practice, so common with mothers and nurses, of admin- 
istering various irritating substances of an anodyne or carmina- 
tive character, is often carried to a highly injurious extent, and 
cannot be too severely censured. The habitual use of opiates in in- 
fantile colic, almost always leads to very unfavorable, and often 
to very distressing and dangerous consequences. In order to ob- 
tain the requisite degree of anodyne effect, the dose must be pro- 
gressively increased; and thus a habit is soon formed, which 
renders the discontinuance of the anodyne a source of inexpressi- 
ble distress and inquietude, whilst its continuance, in increasing 
doses never, fails to operate perniciously on the whole organization. 

Under the habitual use of these treacherous palliatives, consti- 
pation soon ensues; the appetite and digsstive powers fail: the 
body emaciates and the skin becomes sallow, dingy, and shrivelled; 
the countenance acquires an expression of languor and suffering, 
and a general state of apathy, inactivity and feebleness ensues, 
which, ultimately, often leads to convulsions, dropsy of the head, 
glandular indurations, incurable jaundice, or fatal exhaustion of 
the vital energies. The more immediate effects of opiates, also, are 
frequently extremely unpleasant, particularly in very y oun g infants. 



200 OF COLIC. 

The pain may indeed be lulled by the anodyne, but though qui- 
eted, the infant is evidently under the influence of highly disa- 
greeable sensations, as is manifested by the sudden startings, un- 
natural whining cry, and the exceedingly irregular respiration, 
being now very hurried for a moment, and then slow and moaning 
with occasional intermissions, of so protracted a duration, that 
"one would think the breathing had ceased altogether." All 
the usual soothing mixtures, such as Godfrey's cordial and Dalby's 
carminative, so much employed for allaying the colic pains, and 
griping of infants, contain more or less opium; and innumerable 
infants have been irretrievably injured by the habitual use of 
these popular nostrums. 

Heating and irritating articles, such as diluted spirits, infusion 
of spicy and aromatic substances, soot, and repeated active pur- 
gatives may do much injury, by irritating the delicate mucous 
membrane of the stomach and bowels, impairing the digestive 
powers, and finally exciting a state of chronic inflammation in 
this structure, which it is always very difficult, and often impos- 
sible to remove by any subsequent care and management. The 
observations are addressed rather to mothers and nurses than to 
physicians; for it cannot be questioned that all these remedies, 
more especially opiates, may, by judicious management be bene- 
ficially employed in certain instances and conditions of the 
complaint. 



OF CONSTIPATION. 201 



CHAPTER XVII. 



OF CONSTIPATION. 



Torpor of the bowels, and consequent costiveness, of more or 
less protracted duration, is of frequent occurrence among infants. 
In some instances, the bowels are habitually so very inactive, 
that scarcely any alvine evacuations take place, except when excit- 
ed by artificial means. This state of the bowels is the result either 
of a constitutional habit, or of accidental causes. The former va- 
riety of costiveness is very rarely attended with unpleasant con- 
sequences, "and indeed children of such a habit of body are fre- 
quently the most thriving" (Underwood). Dr. Dewees observes, 
that a period of from two to ten days may intervene between the 
stools, in constitutional costiveness, "without the child receiv- 
ing the least injury from this torpor of the bowels." I have re- 
peatedly met with instances, where not more than two or three 
evacuations took place in the course of a week, without the slight- 
est inconvenience to the infant; and Dr. Dewees mentions a case, 
where the stools occurred "but once in eight or ten days," for a 
long period, although the infant throve well and appeared to be 
"in excellent health." .Mothers, generally, express much solici- 
tude, in cases of this kind ; and under the apprehension of evil con- 
sequences from this condition, frequently urge the administration 
of aperients to a very injurious extent. When the infant mani- 
fests no symptoms of ill-health, and continues to thrive well, con- 
stitutional costiveness very seldom requires any remedial interfe- 
rence, "though it will be prudent carefully to watch it." Where 
there is a tendency to convulsive affections — a tendency which is 
sometimes manifested in children of a perfectly healthy and ro- 
bust appearance, it will undoubtedly be advisable to obviate pro- 
tracted costiveness by the occasional administration of suitable 
aperients; for, "fine lusty infants are sometimes seized with vio- 

2D 



202 OF CONSTIPATION. 

lent convulsive fits, without any other apparent cause, than a nat- 
urally costive state of the bowels, and as uniformly recovered from 
the fits, merely by procuring stools and breaking off the wind" 
(Underwood). During dentition, also, it will, in general, be expe- 
dient to increase the frequency of the alvine evacuations, by arti- 
ficial means, where there is much intestinal inactivity. The 
most suitable aperients, in cases of this kind, are castor oil, man- 
na, and magnesia. I have for many years past, been in the habit 
of prescribing the following mixture for this purpose. It is cer- 
tain, and peculiarly mild in its operation, and of so pleasant a taste 
that children generally take it with little or no reluctance. 

R. 01. Ricini - - g i 
Magnesias calcinat. 3 " 

Sacchar. Albi, - - 3 "i 
01. Anise, - - gtt. ii 
Mix them intimately, by rubbing them together in a mortar. 

One or two teaspoonfuls of this mixture may be given at a dose. 
During the first two or three months of infancy, we may, in gen- 
eral, keep the bowels sufficiently soluble by the use of manna — 
an article which is, perhaps, less apt to disagree with the stomach 
or to cause unpleasant effects in the alimentary canal of infants, 
than any other aperient we possess. It should be dissolved with 
warm water, to the consistence of a thick syrup, and given in tea- 
spoonful doses. 

Costiveness from accidental causes is a very common affection 
during infancy. Instances of this kind are, properly, morbid con- 
ditions, and can seldom be entirely neglected without incurring some 
risk of injurious consequences. A torpid state of the bowels may 
occur as a symptom of some obscure deviation from health. If it 
be not removed it may become an additional source of irritation 
in the system, and aggravate the latent disorder upon which it 
depends. Thus a preternatural determination of blood to the 
brain, may give rise to inactivity of the bowels, without any other 
obvious signs of ill-health, or disordered function. The costiveness, 
if it be suffered to continue, will hardly fail to increase the already 
preternatural determination of blood to the head, and thus a very 
serious affection may ultimately be developed in the brain or the 
alimentary canal, which might have been obviated by a judicious 
course of aperient remedies. The occurrence of costiveness dur- 



OF CONSTIPATION. 203 

ing dentition, may always be regarded as an unfavorable event. 
Children almost always suffer much more general irritation, and 
incur much more risk of convulsions and other dangerous affec- 
tions from dentition, when the bowels become torpid and consti- 
pated, than when they are moderately loose during this process. 

The very reprehensible, and frequently clandestine practice, 
among nurses of giving opiates to infants, to make them sleep, 
that they may not require much attention during the night, is a 
frequent source of obstinate and injurious costiveness.* I met 
with a remarkable instance of this kind a few years ago. The 
infant, when about two months old became very costive. Aperi- 
ents were from time to time, resorted to, but the torpor of the 
bowels continued, and gradually increased, until no evacuations 
could be procured except by large doses of the most active pur- 
gatives. The child became sickly, and much harassed with acid- 
ity and flatulent pains in the stomach. After I had for nearly a 
month endeavored to bring the bowels into a more regular condi- 
tion, without the slightest advantage, it was accidentally ascer- 
tained that the nurse had been in the habit of giving the infant a 
dose of laudanum every evening to the extent of at last ten or twelve 
drops at once. The laudanum was now gradually withheld, and in 
about two weeks the child's bowels were restored to their former 
regular state, although its general health continued to be very 
infirm for several months afterwards. 

Costiveness may also occur, as a consequence of particular arti- 
cles of nourishment. Children who are chiefly nourished by 
pap, or by preparations of rice, are apt to become more or 
less constipated ; and in general, all the usual farinaceous ar- 
ticles of nourishment have a greater tendency to produce 
costiveness, than milk and the nutrient animal fluids. In 
some instances, though rarely, the mother's or nurse's milk, 
has a constipating effect on the child's bowels: but this, prob- 
ably, depends more frequently on a peculiar constitutional habit 

* "Nurses," says Dr. Dewees, "are now so familiar with this drug (laudanum) that it 
is as regularly carried about them as their scissors or thimble, and is much more indispen- 
sable to their comfort than either of those emblems of industry. If the child does not go 
to sleep, or if it is even feared it will not, at the exact moment which will suit the arrange- 
ments of the nurse ; or if it cry from any cause, so as to give any additional trouble, laud- 
anum is given to make 'assurance doubly sure.' " 



204 OF CONSTIPATION. 

on the part of the child, than on the particular qualities of the 
milk. This was certainly the case in one instance which came 
under my notice some years ago. The mother, with an abundance 
of milk, suckled her twin infants, and treated them in every res- 
pect precisely alike. One of them was constantly costive, except 
when nourished principally with cow's milk; whilst the other 
child was uniformly regular in its bowels. When children are ob- 
served to become costive, and to continue so under the use of any 
particular kind of nourishment, an immediate change of food 
should be made; for a nourishment which is capable of produc- 
ing this effect, will, in conjunction with the costiveness it has caused, 
be likely to occasion more serious disturbances in the system if its 
use be persisted in. 

Accidental costiveness is usually attended with flatulency and 
occasional attacks of colic pains. If it be suffered to continue, it 
may ultimately give rise to inflammatory irritation of the mucous 
membrane of the bowels, which may manifest itself either by obsti- 
nate and painful diarrhoea, or swelling, tension and soreness of the 
abdomen, or finally, by various sympathetic affections of the head, 
chest or the general system. 

The aperients already mentioned, will in general procure all 
advantages that can be derived from remedies of this kind. Cold- 
pressed castor oil, is an excellent laxative in the ordinary cases of 
costiveness. When the alvine discharges manifest a deficiency of 
bile — that is, when they are whitish or clay-colored, much bene- 
fit may be obtained, from the occasional administration of a small 
dose of calomel in the evening, followed next morning, by one or 
two teaspoonfuls of castor oil. Magnesia is the appropriate laxative 
when the intestinal torpor is accompanied with acidity in the 
prima? via;. In moderate cases of constipation, relief may frequent- 
ly be obtained from the daily introduction of a soap suppository into 
the anus. Laxative enemata also, may be advantageously em- 
ployed in cases of this kind. They are especially useful, as occa- 
sional substitutes for the internal aperients, where the necessity 
of resorting to artifical means for moving the bowels continues a 
long time; for a long-continued and frequent employment of even 
the mildest laxatives, is apt to injure the digestive functions, and 
to give rise to some degree of intestinal irritation. When the 



OF VOMITING. 205 

abdomen is free from tenderness or soreness to pressure, frictions 
and gentle kneading of the abdomen with the hand, sometimes 
produces an excellent effect, both in constitutional and accidental 
colic. 



CHAPTER XVIII. 



OF VOMITING. 



Vomiting occurs more frequently, and, in general, with much 
less unpleasant consequences during early infancy, than at any 
other period of life. We often see perfectly healthy infants, who 
are in the habit of throwing off a portion of the contents of the 
stomach, several times daily, without sustaining the least disagree- 
able consequences from it, whatever. The vomiting in these ca- 
ses arises solely from an overloaded condition of the stomach, and 
is not attended either by nausea, or by any strong and disagreeable 
vomitive efforts. It seems to be almost entirely effected by a sudden 
momentary contraction of the stomach, with little or no aid from 
the abdominal muscles and diaphragm. This harmless kind of 
vomiting is particularly apt to occur, in robust infants who are 
nourished at exuberant breasts; and it seldom happens except 
immediately after the infant has sucked. The milk is generally 
thrown off, in an unchanged condition; and the infant is so little 
annoyt: 1 by the vomiting that it will often preserve its usual placid 
and cheerful countenance, whilst the milk is regurgitating from 
its stomach. This variety of vomiting may therefore be regard- 
ed, rather as a salutary than a morbid occurrence; for the super- 
abundant nourishment with which the digestive organs are habit- 
ually overloaded, would, doubtless, soon give rise to indigestion 
and its various disagreeable consequences, if the stomach did not 
regularly relieve itself by throwing off a portion of its oppressive 
load. So long as the infant remains healthy, and the ejections 



206 OF VOMITING. 

are, manifestly, mere efforts of the stomach to relieve itself of its 
over-distended condition, nothing ought to be done, in the way of 
remedial applications, to prevent the vomiting. Nevertheless, 
these efforts of the stomach to relieve itself, though obviously salu- 
tary, show, that the infant is habitually going beyond the proper lim- 
its of moderation in its nourishment; and as a frequent repetition 
of this error, however transient in its influence, may ultimately 
weaken the tone of the digestive organs or establish a habit of 
immoderate indulgence in eating, it will always be proper, to en- 
deavor to obviate the cause of the vomiting — namely the over-reple- 
tion of the stomach, by preventing the infant from taking too much 
nourishment at a time. With this view, " the child should be taken 
from the breast, the moment it begins to dally with it, or as soon as 
it ceases to draw as if it were really gratifying a necessary and pro- 
per appetite." When the infant has satisfied its appetite, it ought 
not to be immediately jolted and dandled, but suffered to remain 
perfectly at rest, for at least thirty minutes, after it has been taken 
from the breast. The common practice of tossing and jolting 
infants immediately after they have taken nourishment is highly 
improper. In cases of the kind now under consideration — where 
the stomach is usually charged to the utmost of its capacity at each 
nursing, this practice is particularly objectionable, as it rarely fails to 
excite vomiting and interfere with the regular progress of digestion. 
If the child is kept in a state of quietude after its removal from 
the breast, and the quantity of its nourishment somewhat dimin- 
ished, in the way just mentioned, the habit of vomiting soon after 
the reception of its food, may almost always be effectually over- 
come. The mere cessation of this inconvenience, however, is 
not the only advantage which may be expected from these mea- 
sures. Infants who are in the habit of vomiting after sucking, 
from mere over-distention of the stomach, are peculiarly apt, at a 
subsequent period, to become affected with habitual torpor of the 
bowels or costiveness. I have repeatedly noticed this connection 
between vomiting from repletion during the early period of infan- 
cy, and habitual costiveness at a more advanced age. It would 
seem as if the excitability of the alimentary canal became, in a 
manner concentrated in the stomach. This consequence might, 
doubtless, be, in a great measure, obviated, by constant attention 



OF VOMITING. 207 

to a suitable moderation in the infant's nourishment. This is the 
only mode by which we may prudently attempt to prevent the re- 
currence of this kind of vomiting. All efforts to obviate the vom- 
iting by medicinal agents, must not only prove abortive, so long 
as the infant is permitted to fill its stomach to excess, but often 
decidedly injurious, and should never be attempted in cases of this 
kind. 

Morbid Vomiting may be excited by injurious or offensive sub- 
stances lodged in the stomach, or occur as a symptom of some lo- 
cal or general affection of the body. Underwood says, that trou- 
blesome vomiting sometimes occurs in consequence of a "suppres- 
sion of the discharge behind the ears; and from the sudden dis- 
appearance of some eruption on the skin." Dr. Dewees, how- 
ever, doubts whether vomiting ever occurs as a direct consequence 
of these causes. " We have never witnessed it," he says "from ei- 
ther of these causes." That such cases do occur, 1 have had un- 
equivocal evidence. I attended a child within the present year, 
affected with frequent vomiting, which was manifestly connected 
with an excoriation and occasional serous discharge behind both 
its ears. It was observed, that whenever there was a discharge 
from these sores, the child was free from vomiting and appeared 
well; but as soon as the serous discharge ceased, which it occa- 
sionally did without any obvious cause, the little patient became 
pale, sickly, and vomited five or six times daily. The infant was 
about eighteen months old. When I first saw it, there had been 
no discharge for five or six days. The parts were perfectly dry 
and scurfy. The child was pale, and threw up almost every 
thing it took into its stomach. I applied blisters behind the ears 
and on the following day no vomiting occurred. By the occa- 
sional application of blisters, and the use of equal parts of lac sul- 
phuris and magnesia, the child finally regained a good state of 
health. This is the only case of this kind, I have met with. 

Dentition is sometimes attended with a very irritable state of 
the stomach giving rise to frequent vomiting. This probably de- 
pends on an extension of the irritation from the mouth to the 
brain, causing a kind of erithism of this organ — a condition which 
is almost invariably associated with an irritable stomach and a 



208 OF VOMITING. 

strong disposition to vomit. The best means for checking this spe- 
cies of vomiting are, blisters applied behind the ears, or on the 
back of the neck; dividing the gums down to the advancing teeth; 
warm pediluvium; purgatives, or purgative enemata; and small 
doses of laudanum. 

Vomiting is sometimes excited by a bad condition in the nurse's 
milk. "When it arises from this cause, the child generally throws 
up the milk almost as soon as it is done sucking. We may read- 
ily satisfy ourselves, whether it depends upon this cause, by put- 
ting the infant upon the use of some other suitable nourishment, 
or suffering it to suckle another nurse. If no vomiting occurs af- 
ter such a change of its nourishment, the source of the evil is man- 
ifest, and a permanent change must be adopted, unless the vomit- 
ing be but trifling. 

One of the most frequent sources of vomiting, however, is a dys- 
peptic state of the stomach, occasioned by improper articles of 
nourishment, or immoderate feeding. These cases are generally 
attended with a prevailing acidity in the prima? vias. The milk 
is thrown up in dense coagula, and has an acid smell; the child 
is troubled with flatulency, acid eructations, and the stools are, 
usually green, more or less griping, and sometimes diarrhoeal. In 
some instances however, the bowels are torpid, and the child expe- 
riences occasional attacks of slight colic pains. In these cases the 
milk or food is seldom thrown up, until it has lain some time in 
the stomach. Dr. Dewees, observes that when the vomiting de- 
pends on an excess of acid, " the milk is thrown up in a few min- 
utes after it has been received into the stomach." This does not 
accord with my own observations. I have seldom known vomiting 
to ensue in cases of this kind, until the milk had lain, at least, a 
quarter of an hour in the stomach, and, in many cases, the inter- 
val between receiving it and throwing it off again, is much longer. 
In such cases, the diet ought to be carefully regulated, and 
above all, moderation in the quantity of food taken, rigidly en- 
joined. If the child has been weaned, much benefit may some- 
times be obtained by mixing its usual farinaceous nourishment or 
milk, with beef or chicken tea, or weak mutton broth. Equal 
parts of barley-water and chicken tea forms an excellent nour- 
ishment, where there is a strong tendency to acidity in the stom- 



OF VOMITING. 209 

ach. To arrest the vomiting, lime-water, and milk, given in 
repeated doses, often produces an excellent effect, where the 
cause of the evil consists in a redundancy of acid in the primas 
vise. If costiveness or slowness of the bowels attend, small and 
frequent doses of calcined magnesia, are preferable; and I have 
occasionally administered the bi-carbonate of soda, dissolved in a 
very weak infusion of colomba with prompt and complete ad- 
vantage in instances of this kind. 

Acid is not, however, always present in cases of vomiting, de- 
pending on a deranged condition of the digestive organs. In 
some instances, there is a total deficiency of acid; the milk, com- 
ing up in a perfectly unchanged state, and wholly free from any acid 
smell. The vomiting in such cases, seldom takes place, until the 
nourishment has lain a considerable time in the stomach, and it is 
generally preceded by very obvious signs of nausea. The child's 
countenance becomes pale and expressive of great anxiety and 
distress, and in a moment the contents of the stomach are thrown 
with great force. In cases of this kind, a teaspoonful of good 
lisbon or maderia wine, given at proper intervals sometimes pro- 
duces a very happy effect. A drop or two of nitric acid, in a lit- 
tle sweetened water, also forms an excellent remedy in such 
cases. Dr. Dewees, says that he has rarely failed procuring 
relief, in this condition of the stomach, "by the occasional exhi- 
bition of small quantities of lemonade." I have used a mixture of 
the spiritus mendiriri and lemon syrup, in several instances, with 
prompt and complete success. Three ounces of the former, with 
an ounce of the latter, forms a good mixture for this purpose. A 
teaspoonful of this may be given every half hour, or at remoter 
intervals according to the urgency of the case. 

When the vomiting is excited by the presence of improper 
articles of nourishment in the stomach, the exhibition of a mild 
'emetic will often prove decidedly beneficial. Four or five grains 
of ipecacuanna, may be given without the least risk of injury, 
and generally with much advantage. I have always preferred 
this article, to antimonial wine, in the gastric affections of infants 
when a remedy of this kind was deemed proper. It is much less 
apt to irritate the mucous membrane of the alimentary canal and 
to debilitate the system than antimony; and its secondary effects 

2E 



210 OF VOMITING. 

are, in general, much more salutary, in cases attended with an 
irritable condition of the stomach, than those of the latter article. 
We may, however, frequently procure the entire evacuation of 
the offensive substances lodged in the stomach, in cases of this 
kind, simply by the exhibition of warm water, by which the vom- 
iting is, at first, promoted, and the stomach freed of its offensive 
contents. If, after this has been effected, the vomiting does not 
cease, a few drops of laudanum or of camphorated spirit, given in 
a little milk, will generally prevent its recurrence. 

We, however, often meet with cases of vomiting in infants, 
which are neither excited by an excess of acid, nor by improper 
articles of food nor by any other offensive substances lodged in 
the stomach, and for which, in fact, we can assign no other cause 
than that the stomach has, from some circumstance or other, be- 
come extremely irritable. In cases of this kind — that is, when 
the stomach is morbidly irritable and the matter thrown up, con- 
tains little or no acid, we may sometimes do much good by the 
administration of minute doses of calomel and ipecacuanna. I 
have repeatedly succeeded in arresting vomiting, from inordinate 
gastric irritability in infants, by exhibiting the eighth of a grain 
of calomel with the one sixth of a grain of ipecacuanna every 
hour or two, in conjunction with the application of a stimulating 
poultice or plaster over the epigastrium. The application of a 
poultice of this kind, is calculated to operate beneficially, what- 
ever may be the cause of the vomiting. A teaspoonful of pulver- 
ized cloves, with the same quantity of black-pepper, formed into 
a poultice with crumbs of bread and water, will, in general, 
answer this purpose very well. A handful of dried mint, rubbed 
up and made into a poultice with meal or bread, forms, also, an 
excellent stimulating application in this condition of the stomach. 
With the exception of small doses of laudanum, internal stimula- 
ting remedies seldom procure more than very transient relief, and 
may readily occasion a great deal of mischief, where there is 
much irritability of the stomach. The occasional use of laxative 
enemata, will sometimes assist materially in such cases. When 
opiates are deemed proper, no preparation, I am inclined to think, 
is more suitable, in this state of the stomach, than the common 
paragoric tincture of the shops. All the purposes however, that 



OF DIARRHOEA. 211 

opium is capable of fulfilling may be fully obtained by applying 
it externally. One or two grains of morphia sprinkled on the 
surface of a small plaster of common cerate, and laid over the 
pit of the stomach, will procure a sufficient degree of narcotic in- 
fluence. When the skin is broken, this article will operate as 
promptly, and with nearly the same degree of energy as if it 
had been received into the stomach. 



CHAPTER X X. 



OF DIARRHCEA. 



Although by no means peculiar to infancy, diarrhoea is, un- 
questionably, by far more common during this early age, than at 
any other period of life. From the peculiarly susceptible and 
uninured state of the alimentary canal, and the general organic 
feebleness of infancy, it is, also, in general, much more apt to as- 
sume an unmanageable and dangerous character, at this period, 
than at a more advanced stage of childhood or adult age. In 
some instances, the diarrhoeal discharge sare faeculent, and easily 
managed. In others, the stools consist principally of viscid mu- 
cus, streaked, occasionally, with a little blood. Sometimes the 
evacuations are conspicuously bilious. In other cases, the dis- 
charges present a white or milky appearance, accompanied with 
rapid emaciation and prostration; and in some instances they 
consist of a mixture of faeculent matter, mucus and imperfectly 
digested articles of food. Although irritation of the mucous 
membrane of the bowels, constitutes the immediate cause of the 
increased peristaltic action and consequent inordinate discharges, 
yet each of these modifications in the character and appearance 
of the evacuations, is essentially connected with peculiar patho- 
logical conditions, which it is of great practical importance to 
discriminate. It should be observed, however, that the simplest 
or faeculent variety of the disease, may, under improper manage- 



212 OF DIARRHCEA. 

ment or the continued operation of irritating causes pass into any 
of the other modifications— there being no essential difference 
between them, except what arises from the degree of inflammato- 
ry irritation — the portion of the bowels principally affected, and 
the extent to which the digestive powers, as well as the neigh- 
boring structures and organs become implicated in the disease. 
Thus, if there is simple irritation of the alimentary canal without 
much impairment of the digestive functions, the stools will be 
fseculent. If the inflammatory irritation is seated principally in 
the small intestines, and extends itself to the mesenteric glands, 
the discharges will probably be chylous. Should the irritation 
be severe, and chiefly located in the large intestines, the stools 
will be mucous: If the liver becomes unusually excited, bile will 
manifest itself in the evacuations; and when the stomach be- 
comes very irritable and the digestive functions depressed por- 
tions of imperfectly digested food will pass off with the stools. 

The exciting causes of diarrhoea are extremely various. Some 
of them act directly on the mucous membrane of the intestinal 
canal, whilst others affect the bowels, sympathetically, through 
the medium of the general nervous system. Of the former 
variety are all irritating substances received into, or generated 
in the alimentary canal; and of these, by far the most common 
are: irritating, crude, or inappropriate articles of food and 
drink; acrid and vitiated secretions from the liver and intestinal 
exhalents; worms, acid, fresh fruit, — particularly sucb as are very 
sweet &c. The foundation of diarrhoea, in infants, is often laid 
during the first twenty-four hours after birth. The habit of 
gorging the infant's stomach with alimentary fluids, previous to 
the secretion of its natural and congenial nourishment by the 
maternal breasts, often at once, produces a degree of gastric irri- 
tation and feebleness, which predisposes to the occurrence of di- 
arrhoea, colic &c. from the slightest causes. Children who are 
entirely nourished at the breast, are much less apt to become af- 
fected with this complaint, than such as are partly nourished by 
artificial food. There exists, however, great diversity in relation 
to the effects of the same article of nourishment, in different indi- 
viduals. Some infants are invariably purged, when fed with 
cow's milk, — even when considerably diluted with water. In 



OF DIARRHCEA. 213 

some children the ordinary preparations of arrow-root produce 
costiveness, whilst we occasionally find this article to give rise to 
much disturbance in the alimentary canal, and purging. This, 
however, is but seldom the case, its usual effects being rather of 
a constipating character. But it is not from the usual farina- 
ceous and mucilagenous articles, that any particular mischief is 
to be apprehended in this respect. On the contrary, they are 
generally the most appropriate dietitic means for preventing and 
counteracting diarrhoeal affections. It is only, when given to ex- 
cess — when the stomach is habitually overloaded with them, that 
they are apt to give rise to disorder of the bowels. However 
mild and congenial the nourishment maybe, it will be apt to give 
rise to weakness of the digestive powers, and purging, when 
taken in excessive quantities. Over distention of the sto- 
mach, by the immoderate reception of food, seldom, however, 
produces any immediate bad effects in this way. It is in 
general only, hy degrees, that the tone of the stomach is 
thus impaired; and that it gives rise to intestinal irritation and 
purging. Infants who are fed with solid articles of food, seldom 
escape suffering more or less from diarrhoea. The practice of 
allowing potatoes, meat, pastry, dried fruit, and other articles of 
this kind, to infants, is peculiarly calculated to give rise to intesti- 
nal irritation, and all its disagreeable and alarming consequences. 
This injurious practice is seldom confined to the production of 
simple diarrhoea. It is apt, ultimately, to produce a slow form of 
inflammation in the mucous membrane of the bowels, terminating 
often in ulceration or incurable disorganization of this delicate 
structure. Chronic cases of diarrhoea, attended with general irri- 
tation and emaciation, are almost always connected with inflam- 
mation and structural lesion of the intestinal mucous membrane; 
and the majority of such instances are the result of errors in 
diet — particularly of crude and irritating articles of solid food. 

In some instances, the mother's or nurse's milk, disagrees with 
the infant's stomach, and gives rise to troublesome vomiting, colic 
and purging. This does not always depend on any obvious ill- 
health, on the part of the mother or nurse. I have recently seen 
an instance of protracted diarrhoea, in an infant about six months 
old, which was nourished exclusively at the breast, and the mother 



214 OF DIARRH(£A. 

appeared, in every respect, perfectly healthy. The breast was 
withheld, and a mixture of cow's milk and water substituted for 
its nourishment, which had the effect of immediately putting a 
stop to the diarrhoeal affection. The milk, in cases of this kind, 
is, doubtless, in most instances faulty; but it is probable that idiosyn- 
cracy, on the part of the infant, is sometimes the principal if not 
the exclusive source of the mischief, independent of any positive 
bad quality in the milk. When the milk disagrees with the in- 
fant's stomach, the usual consequences, in the first place, are 
vomiting, and acidity. The digestive functions soon become de- 
ranged, and the milk passing into the bowels, in an imperfectly 
digested state, together with the abundant acid usually generated, 
causes intestinal irritation and diarrhoea — the discharges exhibit- 
ing a curdled, stringy, yellow or green appearance. Cases of this 
kind, are generally attended with occasional paroxysms of severe 
colic pains; and the eructations and ejections from the stomach 
have a very acid smell. Irascible and passionate nurses, and such 
as are under the influence of some depressing mental emotion, 
are peculiarly apt to furnish milk of a bad and irritating quality, 
tending to produce diarrhoea, and other forms of intestinal disorder. 
The nourishment, too, which is taken by the nurse has a decided 
influence on the qualities of the milk, and consequently on the 
digestive organs of the nursling. The free use of salted meats by 
the nurse, has a tendency to render the milk acrid or offensive to 
the delicate digestive organs of the infant; and I have known 
very rapid diarrhoea to occur in consequence of a free indulgence 
in eating fresh fruit, particularly cherries, on the part of the 
nurse. 

The influence of dentition on the alimentary canal is well 
known. Many infants are almost constantly affected with loose- 
ness of the bowels during this important process; and when the 
diarrhoeal discharge is moderate, it may be regarded as decidedly 
salutary in its tendency, and ought not to be checked. It has 
been supposed that the immediate cause of the diarrhoea which 
often attends dentition, consists in an acrid condition of the saliva 
— in consequence of the irritation in the gums, extending to the 
salivary glands, and perverting their action. Some degree of 
gastric irritation may occasionally arise from this cause; but the 



OF DIARRHOEA. 215 

principal source of the complaint, appears to consist in a pecu- 
liarly irritable state of the alimentary canal, caused, by the den- 
tal irritation. The whole nervous system often becomes highly 
irritable during the process of dentition. The brain becomes 
remarkably excitable, manifesting in many instances, a decided 
state of erethism, and the whole organization acquires a preterna- 
tural susceptibility to the impressions of exciting causes. In this 
irritable condition of the intestinal canal, therefore, even the or- 
dinary and appropriate kinds of nourishment, may give rise to ir- 
ritation of the bowels and consequent diarrheal discharges. The 
digestive functions may, moreover, suffer derangement from den- 
tition, and favor the production of acid and other causes of intes- 
tinal irritation. 

Cold, by suddenly checking the perspiration and determin- 
ing the blood to the internal organs, frequently gives rise to 
bowel complaints in infants. Cold-bathing, or washing; suffering 
wet diapers, stockings, &x. to remain too long on the infant; 
setting or lying down on damp grass-plats, floors, steps, &c, pass- 
ing suddenly from a close and warm room into the cold external 
air; and exposure to cold and humid weather without sufficient 
clothing — particularly about the abdomen — these are the ordinary 
ways in which diarrhoea, from the influence of cold, is produced in 
infants. Cases arising from this cause, are generally attended with 
slight catarrhal symptoms, more especially with cough; and some 
degree of febrile irritation almost invariably occurs. There is in 
general, a greater tendency to inflammation of the mucous mem- 
brane of the bowels, incases of this kind, than in those produced 
by the other causes of the disease mentioned above. The skin is 
usually dry and harsh, and the discharges are commonly very li- 
quid or watery, containing flocculi of mucus, with little or no 
bilious matter or acid. 

Atmospheric Heat, also, is frequently concerned in the produc- 
tion of this complaint. Its tendency to excite and derange the 
functions of the liver is well known. The occurrence of bowel 
complaints among children, is incomparably more frequent during 
the hot months of summer, than in the colder seasons of the year. 
It is probable that the agency of solar heat in the production of 



216 OF DIARRHCEA. 

bowel complaints, depends as much on the miasmatic exhalations 
which it generates, as on its own direct operation on the animal 
system. It is certain that complaints of this kind, are vastly more 
common in situations favorable for the development of miasmata, 
than in localities not abounding in materials fitted for its genera- 
tion. There can be no doubt, however, that high atmospheric 
temperature, by its direct influence on the system, is capable of 
giving rise to diarrhoeal affections. There appears to subsist a 
direct relation between the liver and the skin; so that when the 
cutaneous exhalents are kept in a state of unusual action by the 
influence of atmospheric heat, the liver, acquires a corresponding 
degree of activity, giving rise to a copious secretion of bile. 
Hence bilious diarrhoea is most frequently met with during warm 
weather. In many cases of diarrhoea from this cause, however, 
there is but very little or no bile perceptibl in the evacuations. 
The liver, in such cases, is torpid and engorged with blood. This 
may arise from the alternate influence of high and low tempera- 
ture. When the skin and liver are in a state of activity from at- 
mospheric heat, the system is extremely susceptible to the impres- 
sions of low temperature. If an individual in this situation is ex- 
posed to the influence of cold or even cool air — as the cool night 
air after a warm day, the cutaneous exhalents and liver are sud- 
denly rendered torpid. The blood, passes from the external to 
the internal organs, and the liver becomes at once greatly con- 
gested and torpid — a condition which is always attended with 
great irritability of the stomach and bowels. Cases resulting 
from these influences, seldom assume the character of simple diar- 
rhoea. They generally occur in the forms of cholera or dysentery. 

Fozculent Diarrhoea. — This is the simplest and in general the 
most manageable variety of diarrhoea. The evacuations are 
feeculent, resembling those which are produced by the operation 
of an active cathartic. The pathological condition of the bow- 
els, in this modification of the complaint appears to consist in sim- 
ple irritation, depending either on the presence of acrid and 
offensive substances lodged in the alimentary canal, or on in- 
creased irritability, in consequence of which the ordinary con- 
tents of the bowels excites excessive peristaltic action and con- 



OF DIARRHCEA. 217 

sequent diarrhoea. When the diarrhoea, depends on the presence 
of acrid or offensive substances in the intestines, it frequently 
cures itself; for as soon as the irritating materials are evacuated, 
the inordinate action of the bowels, usually ceases, and the dis- 
charges assume their natural and healthy character. Perhaps 
the majority of instances of diarrhoea, are, in the first place, ex- 
cited in this way: — that is, by irritating substances either intro- 
duced into the stomach from without, or generated in the intesti- 
nal canal, by fermentation, decomposition, and morbid secretions. 
Very frequently, however, cases, that commence in this way — 
the diarrhoea being at first similar to the purging excited by 
cathartics, — are soon associated with a morbidly irritable condi- 
tion of the bowels; and when this occurs, a spontaneous cure can 
no longer be expected, since the mildest substances will cause 
irritation and inordinate peristaltic action. When the diarrhceal 
discharges continue for three or four days, — more especially after 
the operation of an efficient laxative, we may presume that the 
complaint no longer depends, mainly on the presence of acrid or 
irritating substances, but on a morbid change in the sensibility 
and irritabiltiy of the bowels. Cases of this kind, sometimes as- 
sume a very severe and intractable character, in consequence of 
the supervention of inflammatory irritation or of sub-acute inflam- 
mation in the intestinal mucous membrane. These cases are, 
however, rarely attended with fasculent discharges properly so 
called, and must be ranked with one of the subsequent varieties 
of the complaint. 

The most common source of simple faeculent diarrhoea consists 
probably, in dietetic errors. When the stomach is overloaded 
with nourishment, or when the articles of food are crude, insolu- 
ble and of difficult digestion, more or less disorder of the alimen- 
tary canal is inevitable. If, after an error of this kind, the food 
is not soon rejected by the stomach, portions of it will pass into 
the bowels in an imperfectly digested state, and give rise either 
to severe colic, or to rapid and painful diarrhoea. If the error 
be not repeated, and a moderate and appropriate diet used, cases 
of this kind sometimes cease as soon as the offensive materials are 
evacuated. In general, however, the digestive powers, suffer 
more or less impairment from the irritating impressions and resist- 

2 F 



218 OF DIARRHCEA. 

ance of the improper food; so that even the mildest and most 
congenial articles of nourishment may afterwards fail to be pro- 
perly digested. When this happens, gastric disturbances and 
diarrhoea, of a protracted and obstinate character often occur, 
which can seldom be entirely removed without especial attention 
to the digestive organs. The diarrhoea which results from a bad 
or unwholesome condition of the mother's or nurse's milk, is al- 
ways in the beginning fasculent, and generally remains so through- 
out its course — that is the digestive functions are impaired and 
the bowels in a state of simple irritation. 

In some instances of fseculent diarrhoea, the exciting cause con- 
sists in a superabundance, or in a depraved condition of the bilia- 
ry secretion. In cases of this kind, the evacuations are conspi- 
cuously mixed with bilious matter, sometimes of a dark, but 
more frequetly of a light green color. The appetite is often 
strong, but the digestive powers are almost always impaired. 

Sickness of the stomach, and vomiting, occur much more fre- 
quently in this variety of diarrhoea, than in any other modifica- 
tions of the complaint. This is more particularly the case, when 
the diarrhoea is excited by bad milk, or irritating and inappro- 
priate articles of food. Nausea usually supervenes a short time 
after taking nourishment. This is soon followed by pain in the 
bowels, and more or less rapid purging. When the nausea is 
frequent and considerable, or when vomiting occurs often, we 
may presume, that the morbid state of the stomach manifested by 
these symptoms, constitutes the main pathological condition of the 
disease, and that it requires very especial attention in its remedi- 
al management. This disordered state of the stomach, appears 
to consist of simple irritation and weakness of its digestive ener- 
gies, without any fixed inflammatory irritation or phlogosis. 

Diarrhoea from the application of cold to the body is not often 
of the simple faeculent variety. If, in the beginning of the 
complaint, the discharges are fasculent, which may frequently be 
the case, they seldom continue to exhibit this character through- 
out, more especially when its course is protracted, and other 
sources of gastric derangement are present. The tendency to 
high inflammatory irritation in the mucous membrane of the sto- 
mach and bowels in cases excited by cold, is in general very con- 



OF DIARRHOEA. 219 

siderable, and many instances of this kind, accordingly, early 
assume a much more violent character — the discharges becoming 
watery with floculi of mucus — or mucous with streaks of blood, 
attended with febrile symptoms, and a constant tenderness or 
soreness of the abdomen. 

The occurrence of simple fseculent diarrhoea from dentition is 
very common. When the complaint arises from this cause the 
discharges are sometimes mixed with an abundance of green bile, 
more commonly however there is but very little or no bile, in a 
separate state perceptible in the evacuations. The stomach also 
usually considerably disordered, and the child generally manifests 
a fretful and irritable temper. In some cases the diarrhceal dis- 
charges alternate with short periods of costiveness, and these in- 
tervals of intestinal torpor are almost invariably attended with 
increased symptoms of general irritation. 

Treatment. — It has already been stated that faeculent diarrhoea 
from crude or irritating substances taken into the stomach some- 
times terminates spontaneously as soon as the offensive materials 
are evacuated by the purging which they excite. It would not, 
however, be prudent to rely long on a spontaneous cessation; for 
the irritating cause may be retained many days, notwithstand- 
ing the occurrence of frequent copious and forcible diarrhoeal dis- 
charges, and ultimately give rise to inflammatory irritation in the 
mucous membrane of the bowels. It is, therefore, always the 
safest plan, in cases of this kind, to secure an early and entire ex- 
pulsion of the irritating contents of the bowels, by suitable purga- 
tives. Magnesia is the most appropriate article for this purpose where 
there are indications of acidity in the prims via?. In cases unattend- 
ed with acid in the stomach, castor oil, rhubarb with or without small 
portions of calomel, and in very young infants, syrup of rhubarb, 
are, perhaps, the most suitable purgatives. After the purge has 
operated, the excitement of the bowels ought to be allayed by an 
opiate. The last time, in general, for exhibiting the opiate is in the 
evening. From one to three grains of Dover's powder, according 
to the age of the child, or a few drops of laudanum, should be 
used for this purpose. A suitable dose of Dover's powder in union 
with a small portion of calomel, forms a peculiarly useful anodyne 



220 OF DIARRHCEA. 

in cases of this kind. If the last discharges brought away by the 
purge exhibit an unnatural appearance, or if there is reason to 
think that the bowels have not been entirely freed of their irri- 
tating contents, the purgative ought to be repeated, and again fol- 
lowed by an opiate. The nourishment should be simple and 
bland, and taken in moderate quantities. Arrow root, barley 
water, oat meal gruel, sago, boiled milk, rice, &c. constitute the 
most appropriate articles of diet. Particular care should be ta- 
ken that the stomach be not overloaded with food. The bland- 
est nourishment will be apt to keep up the complaint, if more of 
it be taken at a time, than can be easily digested. The portion 
that remains imperfectly digested, becomes a source of irritation 
to the bowels, and keeps up the disease. 

When in recent cases arising from errors in diet or irritating 
ingesta, considerable nausea or ineffectual efforts to throw off the 
contents of the stomach occur, much benefit may sometimes be de- 
rived from the operation of an emetic. Dr. Dewees recommends 
full doses of calomel, as "the best possible" means for relieving the 
stomach in cases of this kind. It rarely fails to produce pretty 
active vomiting, and operates also as a purge. I have generally 
preferred the use of ipecacuanna, where an emetic was indicated, 
both on account of its mild operation, and its tendency, in minute 
doses, to allay intestinal irritation. After the stomach has been 
well evacuated by the ipecacuanna, a small dose of calomel, fol- 
lowed in the course of three or four hours by a suitable portion of 
castor oil, should be given to remove the irritating contents of the 
bowels. 

Recent cases of faeculent diarrhoea, excited by improper in- 
gesta or errors in diet, generally yield readily as soon as the offen- 
sive materials are evacuated and the bowels tranquillized by an 
opiate. Sometimes, however, the cause that has excited the dis- 
ease, produces, at once, a considerable degree of irritation in the 
mucous membrane of the bowels, in consequence of which the 
diarrhceal discharges continue after the original cause of the 
complaint has been removed. When this happens, and the dis- 
ease continues, purgatives are no longer adequate to arrest the 
progress of the bowel affection. Indeed, it is of great importance 
to bear in mind, that harsh and frequent purging may do a great 



OF DIARRHCEA. 221 

deal of injury by increasing the mucous irritation, and converting 
it into actual inflammation. Simple diarrhoea, is frequently con- 
verted into an aggravated form of the disease, by the injudicious 
practice of exhibiting active purgative remedies, after the bowels 
have been once or twice freely evacuated in the beginning of the 
complaint. It is seldom necessary or proper to employ more than 
two or three active purges in cases of faeculent diarrhoea, from 
transient or temporary exciting causes. To obviate the retention 
and injurious impressions of vitiated secretions, in cases of this kind 
minute portions of calomel and ipecacuanna in union, followed by 
a moderate dose of castor oil generally answers very well. A half 
a grain of calomel with the same quantity of ipecacuanna, for a 
child of from one to two years old, seldom fails to produce a 
sufficient laxative effect. Should it fail, however, its operation 
may be promoted by the administration of a moderate dose of cas- 
tor oil. When faeculent diarrhoea assumes a protracted and ob- 
stinate character, without any decided indications of inflamma- 
tory irritation in the mucous membrane of the bowels, the regu- 
lar employment of small doses of Dover's powder, in union with 
prepared chalk, and minute portions of calomel, together with a 
strict attention to the diet, often produces an excellent effect. A 
powder composed, a grain of Dover's powder, one sixth of a grain 
of calomel, and five grains of prepared chalk may be given two, 
three, or four times daily, according to the age of the patient and 
violence of the complaint. Vegetable astringents, also, often do 
much good in protracted cases of simple diarrhoea, provided the 
mucous membrane of the bowels be free from inflammatory irri- 
tation and the irritating contents of the alimentary canal have 
been properly evacuated by purgatives. They are by no means 
suitable, however, in cases associated with an inflammatory state 
of the bowels, or with an irritable and febrile condition of the 
general system. When the diarrhceal discharges are fasculent and 
very liquid, and unaccompanied by griping and tenderness of the 
abdomen, remedies of this kind often operate very beneficially. 
A decoction of blackberry root, or the root of geranium macula- 
turn, in milk has more frequently succeeded in my hands, than 
any other article of this kind. The geranium root especially, is 
an agreeable and efficient astringent, and may be freely employ- 



222 OF DIARRHCEA. 

ed with but very little or no risk of unpleasant irritation. An 
ounce of the dry root should be boiled in a pint of fresh milk, un- 
til one half is evaporated. From a teaspoonful to a tablespoonful 
of this decoction should be given four or five times daily according 
to the age of the patient. I consider this astringent decidedly pre- 
ferable to the gum kino, so frequently employed for this purpose. 
Kino is more apt to derange the digestive organs and to occasion 
irritation in the mucous membrane of the bowels than the gera- 
nium. The effects of the latter, too, in arresting the inordinate 
action of the bowels, are much more mild, gradual and permanent 
than those of the latter, which though sometimes very prompt, are 
often transient, the complaint recurring after a temporary sus- 
pension. It may be again observed, however, that astringents as 
a general rule, are decidedly improper, in diarrhoea, connected 
with high irritation, inflammation, or structural lesion of the in- 
testinal mucous membrane. 

Cretaceous preparations were formerly almost indiscriminately 
used in the bowel complaints of children. When the complaint 
arises from acidity in the primae vias, and when there are no indi- 
cations of inflammatory irritation of the bowels present, cretaceous 
remedies sometimes produce very excellent effects. They are not 
proper, however, in cases of an opposite character — that is where 
the discharges are mixed with masses or flocculi of mucus, and ac- 
companied with much tormina and soreness of the abdomen. In the 
ordinary bowel complaints of infants, during the summer months, 
there is usually a very considerable tendency to inflammation or 
high vascular irritation of the mucous membrane of the intestinal 
canal, and hence cretraceous remedies often lead to very unfavor- 
able consequences in these cases. 

When faeculent diarrhoea arises from cold, it is almost invaria- 
bly accompanied with more or less conspicuous symptoms of febrile 
irritation. The skin is usually dry and hot, and the patient fret- 
ful and irritable. In some instances of this kind, the evacuations 
are watery, and copious, and passed off with little or no griping. 
More frequently, however, there is a considerable portion of mu- 
cus mixed with the faeces, and the patient experiences severe tor- 
mina. In such cases it will be useful to promote the expulsion 
of the acrid secretions from the bowels, by one or two mild laxa- 



OF DIARRH(EA. 223 

tives; but repeated and active purging, is calculated to do much 
mischief, by increasing the centripetal determination of the circu- 
lation, and favoring the occurrence of inflammation in the mucous 
membrane of the bowels, After the contents of the bowels have 
been freely evacuated by a dose of castor oil, small doses of Do- 
ver's powder and calomel generally prove highly beneficial in 
these cases. One grain of the former with half a grain of the 
latter may be given, twice, thrice, or four times daily, according 
to the age of the patient and the urgency of the complaint. The 
abdomen should be enveloped with flannel, and the feet kept 
warm and dry. The warm-bath may also be used with consid- 
erable advantage in such cases, — particularly when the skin is 
dry and harsh. Astringents and absorbents are entirely inappro- 
priate in cases of this kind. 

In diarrhoea, depending on dentition, it is necessary to proceed 
with much caution in the employment of remedies calculated to 
arrest its progress. Moderate diarrhoea, often exerts a very salu- 
tary effect during dentition. It tends to counteract the preter- 
natural determination of blood to the head, and to diminish the 
cerebral irritation which is apt to occur in difficult dentition. 
Children who are affected with diarrhoea while cutting teeth, are 
much less apt to become affected with convulsions and diseases of 
the brain, than those whose bowels are habitually torpid during 
this important process. If the complaint is moderate, no attempts 
ought to be made to arrest its course by internal remedies. It 
will tend, in some degree, to protect the brain from injurious irri- 
tation, and to keep down the general irritable and febrile condi- 
tion of the system. If the gums are swollen, they ought to be 
divided with a lancet down to the advancing teeth, and particular 
care should be taken that the nourishment be simple, and unirri- 
tating. It is, indeed, of the utmost consequence in cases of this 
kind, to avoid every thing, in the way of diet, that is calculated to 
increase the intestinal irritation. If the patient is permitted to 
use crude or inappropriate articles of food, it will scarcely be pos- 
sible to prevent the complaint from assuming a very aggravated 
and unmanageable character. Diarrhoea from dentition, depends, 
mainly on a morbidly irritable condition of the bowels. If the 
ingesta are bland and adapted to the digestive powers of the 



224 OF DIARRHOEA. 

child, the complaint may go on moderately, and with a salutary 
tendency, until the teeth are protruded. A single error in diet, 
however, may give rise to a state of inflammatory irritation in the 
bowels, which it will be extremely difficult to remove, so long as 
the system is under the influence of dentition. When diarrhoea 
from teething acquires a violent character, advantage may be de- 
rived from an occasional dose of castor oil, opiates, ipecacuanna 
and warm-bathing. There is no variety of diarrhoea in which 
opiates operate more favorably than in cases arising from denti- 
tion. The Dover powder, from its decided diaphoretic tendency, 
is, in general, the best form for using opiates in complaints of this 
kind. I have hitherto, generally, depended chiefly on the use of 
this article, for moderating severe cases of diarrhoea, during diffi- 
cult dentition. It should be given in very small doses, at suffi- 
cient intervals to prevent nausea or vomiting. Ipecacuanna, also, 
is an excellent remedy in cases of this kind. When administered 
in doses of a sixth or a fourth of a grain, it often exerts a very 
tranquillizing influence on the bowels. The dose should be 
repeated every two or three hours. When the evacuations man- 
ifest a deficiency of bile, small portions of calomel should be 
united with the Dover's powders. Care must, however, be taken 
not to carry the use of calomel to the extent of affecting the gums, 
or producing a general mercurial excitement. Astringents are 
wholly inadmissible in these cases. 

Bilious Diarrhoea. — This variety of the complaint is attended 
with inordinate functional activity of the biliary organs. The 
secretion of bile is excessive in quantity, and doubtless, also, fre- 
quently vitiated in its composition. The evacuations are very 
fluid, copious, and mixed with a great abundance of green or yel- 
low bilious matter. The urine is generally conspicuously imbued 
with bile, and when the complaint goes on for two or three days, 
the skin and white of the eyes, usually acquire a yellowish or 
slightly jaundiced hue. Cases of this kind seldom occur during 
the cold seasons of the year. High atmospheric temperature 
appears to be the ordinary remote cause of this modification of 
diarrhoea. It is not improbable, however, that what is usually 
ascribed to the direct influence of solar heat on the animal system, 



OF DIARRHCEA. 225 

in the production of this and other forms of bilious disease, may de- 
pend, mainly on the influence of the miasmata which are always 
more or less abundantly diffused throughout the atmosphere during 
hot seasons, and which are well known to exert a direct and powerful 
influence on the biliary organs. Bilious diarrhoea is much more 
common in situations abounding in materials adapted for the gen- 
eration of malaria, than in localities of an opposite character. In 
populous cities and in marshy districts, this complaint is very com- 
mon during the hot months of the year; whereas in dry, open 
and elevated situations, it is but very rarely met with. 

In some instances, the bile, though extremely copious, exhibits a 
perfectly natural or healthy character; in other cases, it presents 
an unnatural appearance, and is so acrid, as to cause a severe 
burning sensation in the extremity of the rectum, and sometimes 
very painful irritation about the anus. Cases of the former kind 
are usually easily managed; but the latter, are apt to assume a 
violent and obstinate character, in consequence of the early su- 
pervention of inflammatory irritation in the mucous membrane of 
the intestinal canal. Cases sometimes occur in which the evacua- 
tions are at first highly bilious. After having continued for some 
days, the appearance of bile, in the discharges ceases, and the 
evacuations become watery, without the slightest trace of bilious 
matter. When this change takes place, the stomach, usually, be- 
comes irritable, and the disease assumes the character of chronic 
cholera. The liver in cases of this kind, appears to be torpid, 
from great sanguineous engorgement. 

Diarrhoea of a highly bilious character, is sometimes produced 
by improper nourishment, or by bad milk. These cases are most 
apt to occur during the first two or three months of infancy, and 
are generally associated with much acidity in the primae vise. 
When the disease is excited in this way, the discharges are gene- 
rally of a bright-green color, and attended with severe griping. 

Treatment. — In the treatment of this modification of diarrhoea, 
the indications, are, to remove the acrid secretions out of the 
bowels, to subdue the morbid irritability of the intestinal canal, 
and to correct the functional derangement of the biliary organs. 
The bowels should, in the first place, be thoroughly- evacuated 

2 G 



226 OF DIARRHCEA. 

by a suitable dose of castor oil. After this has been effected, mi- 
nute portions of calomel and ipecacuanna must be given, in 
repeated doses during the day, and an opiate in the evening. The 
fourth of a grain of calomel with the same quantity of ipecacu- 
anna may be given every two or three hours, to a child under 
three years old, and continued until the character of the evacua- 
tions is improved. Minute portions of calomel are, in general, 
more beneficial in diarrhceal affections, associated with an excess 
of bile, than large and purging doses. When large doses are fre- 
quently repeated — more especially in infants — they sometimes 
give rise to much irritation in the mucous membrane of the ali- 
mentary canal; and they are, moreover, less apt to allay the mor- 
bid irritability of the bowels than very small doses. 

To prevent the retention and accumulation of vitiated or irri- 
tating secretions in the bowels, it will be proper to exhibit an oc- 
casional dose of castor oil; or an additional portion of calomel 
may be given, once daily, or every other day, according to the 
effects of the ordinary doses and the character of the evacuations. 
Opiates, are in general, much less useful in this variety of diar- 
rhoea than in the preceding one. If the patient is free from fever, 
advantage may be obtained from a few drops of laudanum, or a 
moderate dose of Dover's powder administered in the evening, 
particularly after the operation of a purgative; but opiates ought 
not to be employed for the purpose of arresting the diarrhceal dis- 
charges so long as the evacuations are characterized by a super- 
abundance of bilious matter. Astringents and absorbents are 
still more objectionable. The principal object to be kept in 
view, in the treatment of this variety of the complaint, is to cor- 
rect the functional disorder of the biliary organs; so long as this is 
not accomplished all attempts to restrain the inordinate action of 
the bowels, by opiates or astringents, must not only be abortive, 
but often highly injurious. Should the evacuations assume a na- 
tural appearance, and the diarrhoea, notwithstanding continue, it 
will then be proper, to administer small doses of Dover's powder 
in union with the calomel, in order to subdue the morbid irrita- 
bility of the bowels. 

In cases attended with febrile irritation, recourse should be had 
to antimonials. A few drops of antimonial wine, or a teaspoon- 



OF DIARRHOEA. 227 

ful of a solution of tart, emetic, of the strength of a grain to two 
ounces of water, should be given every hour or two. James' 
powder is an excellent antiphlogistic in cases of this kind. It 
may be very advantageously given in union with calomel. I have 
often used the following mixture with very decided benefit in such 
cases. A teaspoonful of it, should be given every two or three 
hours. 



Spirit Menderiri 
Spirit Nit. Dulc. 
Vir. Antimonii 
Tinct. Opii. 



SB. 

gtt. 



Some advantage may also be obtained from warm bathing, 
and from the free use of mucilaginous diluents, such as barley 
water, slightly acidulated with lemon juice. When the abdomen 
becomes tender or sore to pressure, the application of a large emo- 
lient poultice over the abdomen, and renewed from time to time, 
is calculated to do much good. When the abdominal tenderness 
is attended with very thin discharges — resembling a solution of 
verdigris in turbid water, containing flakes of intestinal mucous, 
purgatives must be very cautiously employed. Frequent purg- 
ing, under such circumstances, could scarcely fail to aggravate 
the intestinal irritation. The small doses of calomel and ipecac- 
uanna mentioned above, in conjunction with an occasional pur- 
gative enema, will, in general, suffice to prevent the undue re- 
tention and accumulation of acrid substances in the bowels. 
Should a purgative be deemed necessary, however, castor oil, 
with a few drops of laudanum, is decidedly the best article. 
After the purge has operated, the bowels ought to be tranquil- 
lized by an efficient dose of laudanum or Dover's powder. 

Mucilaginous diluents may be freely allowed; and in the present 
variety of the complaint, slightly acidulated drinks, are often pecu- 
liarly grateful, and I have never known any ill effects to result 
from their use. The diet ought to be of the simplest and bland- 
est farinacious substances. Thin preparations of arrow-root, ta- 
pioca, sago, rice, barley, and boiled milk, constitute the most 
suitable nourishment in cases of this kind. Animal fluids — such 
as beef or chicken tea, are apt to irritate the bowels and to ag- 
gravate the diarrhfleal affection. After the disease has been sub- 



228 OF DIARRHCEA. 

dued, a mixture of equal parts of a thin preparation of arrow-root, 
and beef or chicken tea, forms a very proper nourishment; but 
during the continuance of the bowel complaint the patient ought 
to be restricted to the exclusive use of the mucilaginous articles 
just mentioned. The body should be carefully protected against 
the injurious influence of cold. Cool and damp night air, after a 
warm day, is particularly apt to excite or aggravate bilious diar- 
rhoea. Children affected with diarrhoea ought not to be washed 
with cold water. This precaution is particularly proper in very 
young infants. 

Mucous diarrhcea. — In this variety of diarrhoea, the mucous 
membrane of the bowels is in a much more irritated condition 
than in the two preceding modifications of the complaint. In 
fasculent and bilious diarrhcea, the irritation is chiefly located in 
the small intestines; but in the present form, its principal seat is 
in the colon and rectum. In some instances the evacuations con- 
sist almost entirely of intestinal mucus; but in the majority of 
cases a considerable portion of fasculent matter of an unnatural 
appearance passes off with the mucus. The mucus is generally 
the last portion evacuated, and in many instances a small quan- 
tity of unmixed mucus precedes the faeculent portion of the dis- 
charge. The evacuations are seldom very frequent or copious. 
They are sometimes streaked Avith blood, and a slight degree of 
tenesmus and straining occurs in many cases. The discharges 
are usually preceded by severe tormina, and in protracted cases, 
the abdomen becomes decidedly tender or sore to pressure. 
Mucous diarrhcea, in fact, differs only in degree from dysentery. 
When neglected or mismanaged it sometimes assumes all the 
characteristic phenomena of the latter form of intestinal disease. 
It may be regarded as a catarrhal affection of the bowels, and is 
produced, generally, as other catarrhal affections are, by cold — 
causing a sudden torpor of the cutaneous exhalents. In miid 
cases, the mucus, usually, presents its ordinary natural appear- 
ance; but when the disease continues for sometime, and assumes 
a more severe character, it, generally becomes opake and whit- 
ish resembling cream or pus. The appearance of the whitish 
or puruloid matter in the evacuations, indicates the existence of 



OF DIARRHCEA. 229 

inflammation in some portion of the mucous membrane of the 
bowels, and is always to be regarded as a highly unfavorable 
symptom. Cases of this kind, are generally attended with slight 
febrile irritation, and the skin is almost invariably dry and harsh. 

Treatment. — Dr. Dewees recommends the daily exhibition of a 
moderate dose of castor oil, and an opiate in the evening until 
the bowels are relieved. This mode of treatment, will frequently 
put a speedy stop to the disease; but the daily exhibition, of 
even so mild a purge as castor oil, may do serious injury, 
by aggravating the mucous irritation of the bowels. I am quite 
certain that I have seen mild cases pass into severe or purulent 
ones, under the daily employment of purgatives; and I am equally 
satisfied that daily purging is, in general, altogether unnecessary 
to the safe and successful treatment of the complaint. The dis- 
ease, as has already been stated, is generally brought on by a 
sudden suppression of the perspiration. An important object, 
therefore, in its remedial management, is to restore the regular 
action of the cutaneous exhalents. In the commencement of the 
treatment, the bowels ought to be freely evacuated, by an effi- 
cient dose of castor oil, to which a few drops of laudanum should 
be added. After the oil has operated, small doses of ipecacuanna 
and calomel should be given at regular intervals, and a full dose 
of Dover's powder in the evening. To an infant of between one 
and two years old, a fourth of a grain of the former with the sixth 
of a grain of the latter, may be given every two hours. 

When the evacuations are attended with severe tormina, and the 
patient is free from fever, small doses of Dover's powder should 
be occasionally substituted for the ipecacuanna. To prevent the 
retention of irritating substances in the bowels, a mild laxative 
clyster should be administered, once or twice daily. A few 
drachms of manna dissolved in a gill of warm water, — barley wa- 
ter with a teaspoonful of common salt, or molasses-water, form 
proper mixtures for this purpose. When the stools are frequent 
and small, and the patient is observed to remain a long time on 
the vessel and to strain, mucilaginous injections with a suitable 
portion of laudanum, generally afford very considerable relief. 
Should the disease continue for three or four days, a second dose 



230 OF DIARRHOEA. 

of castor oil and laudanum may be given, if the ipecacuanna and 
calomel, together with the laxative enemata do not appear to 
free the bowels sufficiently of their vitiated contents. To pro- 
mote the action of the cutaneous exhalents, warm bathing, will 
be useful; and a broad flannel roller should be worn next the 
skin, round the abdomen. The drink and diet should be mucila- 
ginous. All solid food is decidedly objectionable. When the 
disease assumes a chronic character, with a puruloid appearance 
of the mucous discharges, considerable benefit may sometimes be 
derived from small doses of balsam capaiva, in the form of an 
emulsion. From five to ten drops of the balsam may be given 
two or three times daily, together with a few drops of laudanum. 
I have frequently employed this article in conjunction with mi- 
nute portions of Dover's powder with the happiest effect in cases 
of this kind. 

Chylous diarrhcea. — In this variety of diarrhoea, the evacuations 
are of a whitish or milky color with a manifest deficiency of 
bilious matter. The principal irritation, in cases of this kind, is 
evidently seated in the upper portion of the small intestines. 
The mucous membrane of this section of the bowels, appears to 
be in a sub-inflamed condition; in consequence of which, the sen- 
sibility of the mouths of the lacteals is so changed or perverted as 
to prevent them from taking up the chyle. The tormina or 
griping is always felt in the upper part of the abdomen; and the 
epigastrium is almost invariably somewhat distended, and tender 
to pressure. The hands and feet are apt to be cold ; and the skin 
usually acquires a peculiarly sallow appearance, more especially 
in cases of protracted duration. The patient is soon much weak- 
ened, and emaciation generally goes on very rapidly. Chylous 
diarrhoea, is seldom attended with distinct febrile symptoms, but 
the nervous system often becomes morbidly irritable. 

This variety of diarrhoea occurs under very different degrees 
of violence and duration. Recent cases, excited, suddenly, by 
irritating or improper articles of nourishment or cold, are usually 
mild and of easy management; but when the complaint comes on 
slowly, in consequence of long-continued derangement of the di- 
gestive organs, or habitual disturbance of the bowels, it frequently 



OF DIARRHCEA. 231 

assumes a chronic and very obstinate character, so as sometimes 
to resist remedial effort. 

Dr. Dewees, thinks that the absence of bile in the duodenum, 
constitutes the principal cause of the chylous evacuations. The 
want of bile, he conceives, will prevent the healthy elaboration 
of the chyme, in consequence of which it will "act upon the sus- 
ceptible bowels," as an irritant, and "urge them to an increased 
peristaltic motion." 

It may be observed, however, that the absence of bile in the 
duodenum generally produces a very different effect, from that 
which is ascribed to it in this explanation. Torpor of the bowels 
and constipation are the usual consequences of deficient biliary 
secretion, and it appears moreover from, the experiments of Tied- 
eman and Gruelin that the presence of bile is not necessary for 
healthy elaboration of the chyme. It seems more probable that 
chylous diarrhoea depends on a highly irritable and irritated con- 
dition of the mucous membrane of the small intestines, more es- 
pecially of the duodenum, in connection with an impaired and 
imperfect performance of the digestive functions. The absence 
of bile in the evacuations is, perhaps, occasioned by a spasmodic 
constriction of the orifice of the bile duct; and the lacteals may 
fail to take up the chyle from a similar condition of their mouths. 

Treatment. — The principal indications are, to allay the irrita- 
bility and irritation of the duodenum, and to restore the healthy 
functions of the digestive organs. Purgatives are wholly inad- 
missible in the treatment of this variety of diarrhoea. Minute 
doses of calomel and Dover's powder, in conjunction with emo- 
lient or stimulating applications to the epigastrium, warm bath- 
ing, and proper dietetic regulations, constitute the principal 
means for combating this affection. The sixth of a grain of cal- 
omel, with a fourth of a grain of Dover's powder, should be given 
every two or three hours, until the evacuations become bilious. 
A stimulating plaster or a large emolient poultice should be laid 
over the upper part of the abdomen. A plaster composed of a 
tablespoonful of powdered cloves, the same quantity of black pep- 
per, a few teaspoonfuls of cayenne, and two tablespoon fuls of 
flour, mixed up into the consistence of paste with strong vinegar, 



232 OF DIARRH(EA. 

forms an excellent stimulating application for this purpose. A 
simple emolient poultice, will, in general, do much good, in cases 
of this kind. In severe and obstinate cases, recourse should be had 
to the application of a blister over the epigastrium. The plaster 
should not be left on the skin more than three or four hours. If it 
is removed, as soon as the skin is slightly inflamed, and an emolient 
poultice laid over the part, a fine blister will be raised in the 
course of a few hours, and procure all the advantage that can be 
obtained from vesication, without subjecting the child to the se- 
vere pain which commonly attends the usual mode of blistering. 

In a few instances of this modification of diarrhoea, I have ob- 
tained much benefit from small doses of the muriated tincture of 
iron and laudanum. Two drops of the former with a drop of the 
latter, may be given three or four times daily. A mixture com- 
posed of three or four grains of powdered chamomile flowers, a 
grain of Dover's powder, and a fourth of a grain of calomel, taken 
three times daily, will, also, sometimes operate very beneficially. 
Whatever remedies may be emploj^ed, a strict attention to pro- 
per dietetic regulations is indispensable to success, in treatment 
of this affection. All solid food must be rigidly forbidden. Noth- 
ing but the simplest mucilaginous fluids should be allowed — such 
as barley water, very thin arrow root, prepared without milk, 
gum arabic water, a liquid preparation of sago, tapioca, rice wa- 
ter, or a mixture of equal parts of cow's milk and water. It is 
particularly necessary to avoid taking much food at a time; and 
the intervals between the meals should be sufficiently long to en- 
sure the entire digestion of the food last taken, before fresh nour- 
ishment is received into the stomach. 

Lienteric Diarrhoea. — In this variety of diarrhoea, the evacu- 
ations, along with more or less vitiated fasculent matter, mucus, oc- 
casionally bile, contain articles of food in an imperfectly digested or 
wholly unchanged condition. At first the discharges do not occur 
until several hours after eating: but if the disease is suffered to 
continue, the intervals between the reception of food and its evac- 
uation by the bowels, becomes shorter and shorter, until at last al- 
most every thing that is taken into the stomach is speedily thrown 
off again by the intestines. Soon after eating, the patient, usual- 



OF DIARRHOEA. 233 

ly, experiences a good deal of uneasiness in the epigastric and 
umbilical regions. This is in a short time followed by severe tor- 
mina, which in a few moments terminates in a rapid diarrhoeal evac- 
uation. In many cases, however, the discharges occur with but 
very little or no griping whatever. The appetite is always much 
deranged. In some instances it is weak and capricious, loathing 
almost every thing, but a few particular, and generally strong, 
articles of food. In other cases the desire for food is voracious; 
and the most crude, irritating and high-seasoned articles are those 
which are often the most desired. In cases of this kind the abdomen 
is freqently very tumid and hard, and the extremities and body ema- 
ciated. Moderate pressure on the abdomen seldom occasions any 
decided manifestation of tenderness or pain; but a sudden conclu- 
sive agitation of the body, such as coughing or sneezing, or jump- 
ing from a chair, &c. almost always gives rise to a feeling of sore- 
ness and pain in the epigastric and umbilical regions. In the ma- 
jority of instances, there is but very little or no bile observable in 
the evacuations. Occasionally, however, the stools are mixed 
with a considerable quantity of dark green bilious matter of a 
glairy consistence, or of a bright green fluid, resembling a solution 
of verdigris in water. 

This form of diarrhoea very seldom, if ever, arises from the 
operation of a temporary exciting cause. It generally comes on 
gradually, as a consequence of mismanaged faeculent or bilious 
diarrhoea, or from the habitual use of irritating articles of food, in 
conjunction, perhaps, with other causes capable of deranging the 
digestive organs. 

Lienteric diarrhoea may be regarded as a violent form of indi- 
gestion accompanied with excessive irritability and subinflamma- 
tory irritation of the stomach and small intestines. In chylous 
diarrhoea, the morbid irritability and irritation is principally lo- 
cated in the small intestines, more especially in the duodenum, 
without much impairment of the digestive powers; whereas, in 
the present variety of the complaint, the stomach is manifestly 
the principal seat of the disease. The mucous membrane of the 
stomach is probably always in a subinflamed condition in violent 
cases of lienteric diarrhoea. In some instances, the morbid condi- 
tion of the mucous membrane, extends throughout nearly the 

2 H 



234 OK DIARRHOEA. 

whole tract of the intestinal canal. In cases of this kind, the ap- 
petite is often quite voracious, the abdomen is tumid and tense, 
and the evacuations are generally mixed with an abundance of 
mucus. These cases are to be regarded as instances of chronic 
diarrhoea, attended with a morbidly irritable and enfeebled con- 
dition of the digestive organs, and are always connected with 
chronic inflammation, and frequently ulceration of the mucous 
membrane of the colon. In general, when chronic diarrhoea is 
the consequence of irritating substances taken into the stomach, 
and the digestive powers are much disordered, the evacuations, 
are apt to assume more or less of a lienteric character. 

Treatment. — It is obvious, from what has been said in relation 
to the pathology of this variety of diarrhoea, that the principal 
objects to be kept in view in its remedial management, are, to sub- 
due the morbid irritability and inflammatory irritation of the sto- 
mach and bowels, and to restore the healthy performance of the 
digestive functions. One of the most important and indispensable 
means for the fulfilment of these indications, is a perfectly bland, 
simple, and moderate nourishment. All solid articles of food 
must be rigidly avoided. If the child is still nursed at the breast, 
no change of course, is necessary, unless there are good grounds 
for believing that the milk is depraved. Thin preparations of 
arrow-root, tapioca, sago, rice, or barley, a mixture of cow's 
milk and water, a solution of gum arabic in water, &c. constitute 
the best articles of nourishment in such cases. The drink too ought 
to be perfectly bland, and cool. Even these bland alimentary 
substances ought to be used in moderate portions. The patient 
can derive no support from the reception of more food than the 
stomach can digest. A small portion only will be digested; the re- 
mainder passes in an undigested state into the duodenum, and keeps 
up the exhausting diarrhoeal discharges. Among the internal 
remedies suitable in cases of this kind, opium, hyoseyamus, muri- 
ated tincture of iron, and very finely powdered charcoal, are deci- 
dedly the most, valuable. In the commencement, two or three 
drops of the muriated tincture of iron with one or two drops of 
laudanum may be given once, twice, or three times daily, accord- 
ing to the age of the patient. I have, in several instances of this 



OF DIARRHCEA. 235 

kind, resorted to the external application of morphia with the 
happiest effect. The tenth of a grain of this narcotic preparation 
applied to a part from which the cuticle has been removed by 
blistering, will procure all the soothing effects of opium, without 
incurring the risk of nauseating the stomach. Calomel is not, in 
general, a proper remedy in this form of diarrhoea. When the 
liver is manifestly torpid, however, minute portions may be given 
once or twice daily, in union with opium; but I have generally 
preferred applying a mercurial plaster over the right hypoch^n- 
drium. Hyoscyamus, in conjunction with small doses of ihe mu- 
riated tincture of iron or of chalybeate wine, sometimes operates 
very beneficially. Thirty grains of good extract of hyoscyamus 
may be dissolved in two ounces of water. Of this solution? three 
or four drops in union with the same quantity of chair oea * e wine, 
or a drop of the muriated tincture, may be gi^n two or three 
times daily, to a child between one and ' nr ee years old. After 
the irritability of the stomach ha? ^en, to a considerable degree 
allayed, small doses of finelr prepared charcoal with minute por- 
tions of opium, freqi'" llJ 7 produce very excellent effects in this 
modification of -rarrhcea. In some instances, however, I have 
found thi= article to increase the gastric irritation; yet in the ma- 
jority of cases, in which I have employed it, its effects were une- 
quivocally beneficial. Five grains of the charcoal, with the 
twentieth of a grain of opium, may be given two or three times 
daily. In addition to the foregoing means, rubefacient or vesica- 
tory applications, can never be neglected without losing very im- 
portant remedial resources in cases of this kind. 

The abdomen should be rubbed with dry flannel, or with some 
stimulating liniment, until the skin become red, several times daily. 
I have known much benefit to result from the application of the 
spice plaster to the abdomen, already mentioned under the head 
of chylous diarrhoea. In severe cases, postulation with tartar 
emetic ointment, or what appears to me better, the application of 
a blister to the epigastrium, may be resorted to with much pro- 
priety. Indeed, I have more frequently made a decided and 
prompt curative impression on the disease by blistering, than by any 
other remedy. The plaster need not be sufficient to remain on 
the skin until the vesication has taken place. When taken off as 



236 OF DIARRHCEA. 

soon as the skin is uniformly red or inflamed, which usually occurs 
in three or four hours, and a soft emolient poultice applied over 
the part, a fine blister will be raised, without subjecting the child 
to much irritation or pain. The blistered surface will afford anexcel- 
lent opportunity for the external application of opiates. Gentle ex- 
ercise, by gestation in the open air, will be a useful auxiliary to the 
means already mentioned. I have known children, who had been 
a long time harassed with this form of diarrhcea in the city to re- 
cover, speedily on being removed into the country. In general 
cases of this kind pass off very slowly. When the disease is con- 
nected with chronic inflammation of the colon, and the abdomen 
is tumid, tense and sore to pressure, it often resists every effort to 
subdue if. I ] iave m one instance of this character, succeeded in 
curing the encase, by use of the conferva helminthocordon. I em- 
ployed a decoction, ma de by boiling two drachms of it in a pint of 
water, down to half a pii> This was administered in teaspoonful 
doses every four hours, in um* n w ith three drops of laudanum. 
The child was between four and five j^ rs old.* 

After the lienteric discharges have ceasea, Hn( j the evacuations 
present a natural feeculent character, benefit ma) he derived from 
small doses of colomba, or powdered chamomile. NoiYA no - f this 
kind, however, must be used until the discharges are decidedly 
and wholly fasculent. Great care should be taken that noth- 
ing but the simplest and most appropriate diet be allowed for sev- 
eral months, after the patient has recovered from the complaint. 
Slight errors in diet may re-excite the disease. 

Chronic Diarrhcea. Atrophia Ablactatorum. — Children are 
liable to two distinct varieties of chronic diarrhoea. The most 
common modification of chronic diarrhoea, generally occurs 
at an early period of childhood, and is manifestly attended 
with prominent derangement of the liver stomach, and small 
intestines. The other variety generally occurs at a more ad- 
vanced age, and corresponds entirely with the chronic diar- 

* I was induced to employ this remedy, by having noticed several obstinate cases of 
chronic diarrhcea, entirely removed by Swaim's Vermifuge — a nostrum, which I have 
sufficient grounds for believing, consists principally, of a decoction of the conferva hel- 
minthocordon. 



OF DIARRHCEA. 237 

rhoea of adults, depending mainly on chronic inflammation, of the 
mucous membrane of the colon. The first of these varieties 
of the complaint, has been well described by Dr. Cheyne, under 
the name of "atrophia ablactatorum," as a new and very pe- 
culiar form of diarrhoeal disease. It differs, certainly very con- 
siderably in its phenomena and pathological character, from 
the chronic diarrhoea of adults; but this difference depends rather 
on the portion of the alimentary canal principally diseased, than 
on any essential diversity in their natures, both being nothing 
more than different modifications of confirmed or chronic states 
of common diarrhoea. When recent cases of bilious or faeculent 
diarrhoea are neglected, or mismanaged, or when the exciting 
cause continues to act, they are apt to assume an aggravated 
and obstinate character, presenting all the appearances that are 
described as characterizing the " weaning brash," or atrophia 
ablactatorum. Dr. Cheyne is of opinion that "this form of chro- 
nic diarrhoea is imputable to an increased secretion of acrid 
bile." The biliary secretion is certainly often very abundant 
and perhaps depraved in cases of this kind; but this morbid 
condition of the bile is probably a consequence, rather than 
the cause of the gastro-intestinal irritation, upon which the 
diarrhoeal affection depends. It seems, to me very clear that 
the exciting causes of this complaint do not differ from those 
which give rise to the usual faeculent and bilious varieties of 
diarrhoea. Gastric irritation from inappropriate articles of 
nourishment, or other errors in diet, appears to be the or- 
dinary source of this complaint. It may be observed, that 
inasmuch as this disease is incomparably more common imme- 
diately after weaning than at any other period of infancy, 
there must be something peculiar in its mode of origin and 
character. It might be expected, however, that a complaint 
which arhes from gastric irritation, produced by inappropriate 
alimentary mgesta, should be much more common at the time 
when the child suddenly passes from the bland and congenial 
nourishment provided for it by nature, to an exclusive and 
frequently illy adapted artificial diet. Few individuals can 
sustain a sudden and total change of food, without experien- 
cing more or less disorder of the stomach and bowels. A 



238 OF DIARRHCEA. 

person who has been a long time confined to animal food, 
will probably become affected with diarrhoea, if he passes 
suddenly to an exclusive vegetable diet. The tendency of 
weaning, to give rise to bowel complaints, is, doubtless, much 
increased by the influence of dentition on the alimentary 
canal. This process, is frequently accompanied with . so much 
irritability of the stomach and bowels, that the mildest articles 
of nourishment are apt to operate as irritants and to excite diar- 
rhoeal discharges. It is easily to be conceived, therefore, that 
diarrhoea must not only be much more frequent, but also more 
violent and protracted when weaning and dentition co-operate 
in deranging the alimentary canal than at any other period. Dr. 
Cheyne says, that, " the disease is most frequent in children who 
are weaned before the eighth or ninth month;" and this corres- 
ponds entirely with my own observations. At this early period, 
teething is usually going on actively, and the powers of the sto- 
mach are in general not yet sufficiently developed, to digest with 
due facility, the artificial nourishment substituted for the mother's 
milk. The liability to gastric derangement and diarrhoea from 
these causes, is much greater when the weaning is abrupt, than 
when it is accomplished, as it always should be when practicable, 
in a slow and gradual manner. When the change is suddenly 
effected, and especially, when the nourishment is unsuitable to 
the delicate and excitable state of the infant's stomach, it can 
hardly fail to occasion some degree of gastric derangement. In 
many instances the stomach gradually accommodates itself to the 
new kind of nourishment, and all inconveniences which may have 
resulted from it at first, disappear. When, however, the diges- 
tive organs and liver are particularly predisposed to morbid excite- 
ment, as they often are during dentition, or when the diec is 
decidedly improper, weaning is apt to be followed by a high 
degree of gastrio-intestinal irritation, or violent and obstiiate diar- 
rhoea. Thus, the artificial nourishment, at first, deranges the diges- 
tive powers; the food remains a long time in the stomach before 
the process of digestion is completed; acid and other irritating 
fluids are generated. These together with the imperfectly diges- 
ted food, irritate the stomach and bowels still more, and excite 
purging. The irritation is extended to the liver, and a redun- 



OF DIARRHOEA. 239 

dant or vitiated secretion of bile takes place. The irritating cau- 
ses being thus progressively increased, and the original exciting 
cause, namely the inappropriate nourishment continued, a high 
state of irritation is established in the mucous membrane of the 
alimentary canal, with great perversion of the hepatic and intes- 
tinal secretions; which, in the majority of instances, finally passes 
into actual inflammation. 

Dr. Cheyne, in the account he has given of the post- 
mortem appearances, states that throughout the whole tract 
of the intestinal canal a number of " singular contractions 
with one or more intus-susceptions," were noticed in every 
instance. " The liver was larger than natural, exceedingly 
firm, and of a bright red colour." The mesenteric glands were 
inflamed and swollen in some instances; in others they were near- 
ly natural. The intus-susceptions were without inflammation or 
adhesions. The contractions were " of a spasmodic kind," 
and could be "permanently dilated again, by pushing the finger 
into them." " These appearances, he says, lead me to imagine 
that the weaning brash in its confirmed state is ascribable to an 
increased secretion of acid bile, or rather to the morbid state of 
the liver which occasions this."* Dr. Dewees, observes, that the 
post-mortem appearances detailed by Dr. Cheyne correspond 
with those made in France by Andral and Cruveilhier. With re- 
gard to the dissections of Andral this is not correct. He distinct- 
ly mentions softening of the mucous membrane of the small intes- 
tines, and other marks of inflammation, as frequently connected 
with fatal cases of this kind. Since I have directed my atten- 
tion particularly to the diseases of children, I have had an op- 
portunity of dissecting but one single subject of this kind. In this 
case the mucous membrane of the pyloric extremity of the sto- 
mach and duodenum was in a highly injected condition; in the 
lower part of the ilium, there were a number of livid patches 
of irregular shape, in this tissue, and the whole length of the co- 
lon was contracted to a size that scarcely admitted my little fin- 
ger. It can hardly be supposed, indeed, that the acrid and irrita- 
ting substances which are continually in contact with this deli- 
cate structure in cases of this kind, could fail to excite some de- 

* Cheyne, On Atrophia Ablactatorum &c. p. 18. 



240 OF DIARRHCEA. 

gree of inflammation in it. During the early stage of the disease 
the mucous membrane of the small intestines is probably only in 
a highly irritable and irritated condition. As the disease advan- 
ces the biliary and intestinal secretions become more and more 
depraved, and the alimentary canal more irritable. The constant 
operation of these irritating causes, ultimately gives rise to 
more or less of inflammation, the irritation is extended to the liver 
and mesenteric glands, and these undergo morbid changes, and 
increase the severity and obstinacy of the disease. This complaint 
occurs most frequently, during the summer and autumnal 
months. Dr. Cheyne says, that he " has seldom, comparatively 
speaking, seen it commence before the solstice, nor after the end 
of the year." The tendency of warm and humid weather to fa- 
vor the occurrence of bowel complaints in children, is well known. 
Solar heat renders the organism irritable, and, both through 
the agency of the miasmata which it engenders, and by its own 
direct influence on the human body, has a very decided tendency 
to excite and derange the biliary secretion. Children who are 
weaned during summer, while dentition is going on, are peculiar- 
ly liable to diarrhoea of a severe and obstinate character. This 
complaint generally commences, in the form of simple bilious diar- 
rhoea. The stools at first are fseculent liquid and mixed with an abun- 
dance of bilious matter of a light green color. In the course of 
four or five days, if it is not counteracted by suitable remedies, 
sickness of the stomach, and occasionally bilious vomiting occur; 
and the purging becomes more frequent and often extremely 
painful. The patient now begins to lose his appetite; more or 
less febrile irritation ensues, attended with great fretfulness, 
restlessness, a warm and obstinately dry skin, and urgent thirst. 
The diarrhoeal discharges gradually become more watery, gri- 
ping and frequent; and the bilious matter, in general, less copious 
than at first. The body wastes, the flesh becomes soft and flabby, 
and the debility increases rapidly. In the course of three or four 
weeks, the fever assumes a regular form, — that is, slight exa- 
cerbations occur regularly once or twice daily, attended with a 
" hectic blush on one cheek," and a very frequent quick and 
corded pulse. " But the most characteristic symptom of this dis- 
ease is a constant peevishness, the effect of unceasing griping 



OF DIARRHCEA. 241 

pain — expressed by the whine of the child, but especially by 
the settled discontent of the features." 

The evacuations are by no means uniform in appearance 
throughout the course of the disease. At first the stools usually 
consist of a yellowish faeculent matter mixed with green bile of a 
glairy or uniform consistence. As the disease advances, and the 
intestinal irritation increases, the bile generally becomes more 
abundant and unnatural, presenting a curdled and dark-green 
appearance mixed with foetid watery discharges. Sometimes the 
evacuations are dark brown, very fluid, and extremely fcetid, con- 
taining flocculi of mucus, and little masses of dark bile. Not un- 
frequently the discharges are, for a short time, ochrey or claycolor- 
ed, and then change again to dark and bilious. At an advanced 
period of the disease, the stools are sometimes mixed with a con- 
siderable quantity of a yellowish white, or puruloid matter; and 
occasionally they eissume a lienteric character, — small portions of 
imperfectly digested food appearing in the evacuations. When 
the discharges acquire a watery flocculent and very fcetid cha- 
racter; or when they become lienteric, or mixed with puruloid 
matter, we may conclude that the mucous membrane of some por- 
tion of the intestines is in an inflamed condition, and that the 
disease will probably resist every effort to remove it. 

This form of diarrhoea, generally runs a very protracted course. 
It seldom terminates fatally " before the sixth or seventh week," 
and in many instances it continues three or four months before 
death takes place. During the first two or three weeks, its 
course may often be speedily arrested by judicious management; 
but when the complaint is mismanaged and suffered to run on for 
four or five weeks, it frequently resists every remedial effort. 
When the disease proves fatal at an early period, it is generally 
from its assuming the form of cholera, or from the supervention of 
convulsions. 

Dr. Cheyne seems to think that dentition has but very little if 
any agency in the production of this complaint. " The weaning 
brash," he says, « I have the strongest reason to believe, has no 
connection with teething farther than they sometimes meet in the 
same child. I have known this disease, in many instances, where 
the gums were neither swelled, nor indurated, nor inflamed, and 

21 



242 OF DIARRHOEA. 

where there was no salivation nor any appearance in the mouth. 
I have seen it where children were cutting their teeth easily; 
and where many of them came without difficulty before weaning, 
still the disease has supervened. But perhaps the strongest argu- 
ment that can be used would arise from the observation which I 
have frequently made, that this disease occurs in children of 
three months; and I have often known it several months before 
teething came on." There can be no doubt, indeed, that the dis- 
ease may, and often does, occur wholly independent of dentition; 
yet that the occurrence of the complaint is much favored by the 
irritation of dentition appears to me equally unquestionable. Dif- 
ficult dentition is, in general, attended with obvious derangement 
of the digestive functions, and its tendency to increase the irrita- 
bility of the stomach and bowels, cannot, I think, be questioned. 
It is, at all events, quite certain, that the instances of this disease, 
in which irritation from teething is manifestly present, are incom- 
parably more frequent, than those in which no signs of dentition 
are observable. I have known bowel complaints in children be- 
fore they were weaned, speedily brought to a favorable termina- 
tion, simply by dividing the inflamed and swollen gums; and 
when the gums are in this condition from teething, in the present 
form of diarrhoea, unequivocal benefit is frequently derived from 
this operation. The observation made by Cheyne, that this com- 
plaint sometimes occurs before dentition commences, does not 
disprove its agency in the production of the complaint, where it 
does occur; but only shows that the disease may come on with- 
out this source of irritation. No one can deny the great share 
which abrupt weaning has in bringing on this disease; and yet it 
occasionally occurs before the child is weaned, or many months 
after the weaning took place. The truth is, this disease does not 
differ materially, in relation to its exciting causes, from other va- 
rieties of diarrhoea. The reason why it is more apt to assume a 
violent and chronic character, must be sought, as has been already 
stated above, in the permanency of its exciting causes, rather 
than in any thing peculiar in their character. 

There is another form of chronic diarrhoea which is common to 
infants and adults, and which differs very considerably from the 
preceding variety, both in its phenomena and pathological character. 



OF DIARRHCEA. 243 

The evacuations in this form of the disease are characterized by 
an abundance of mucus, which, as the disease advances becomes 
mixed with a whitish or cream-like matter, sometimes slightly 
streaked with blood, and occasionally mixed with small portions 
of imperfectly digested food. Except, in the early stage of the 
complaint bile rarely forms a conspicuous part of the discharges. 
In some instances the evacuations are liquid, of a dirty brown 
color, containing an abundance of mucus in the form of flakes and 
small masses of purulent matter. Occasionally the fasculent mat- 
ter mixed with the stools is of a whitish color and of a pap-like 
consistence. The appetite is generally very variable, and capri- 
cious. It is sometimes wholly depressed, though more frequently 
sufficiently active, and sometimes quite voracious. After the dis- 
ease is completely developed, slight febrile irritation generally 
occurs — particularly towards evening and a few hours after eat- 
ing. The pulse is generally frequent, small, quick, and sharp, 
and the skin almost uniformly dry and harsh. The abdomen in 
some cases, becomes tumid and hard, while the body emaciates 
more or less rapidly. The face acquires a pale, contracted and 
morose expression, and the temper becomes irritable and fretful. 
The patient usually experiences very severe colic pains a few 
hours after eating, more especially when the food consists of solid 
articles; and, in general, even the mildest nourishment is followed 
in an hour or two after receiving it into the stomach, by severe 
tormina, flatulency, and rapid diarrhoeal discharges. The abdo- 
men is almost always tender or sore to pressure, and the feet, and 
sometimes the face, ultimately become somewhat cedematous. 
The liver is generally inactive, and the small portion of bile that 
is occasionally discharged, is usually curdled and of a dark green 
or black color. 

This variety of chronic diarrhoea, is seldom met with in chil- 
dren under two years old. It is generally the result of neglected 
or mismanaged faeculent or bilious diarrhoea. Indeed, any of the 
modifications of diarrhoea that have been mentioned, in this chap- 
ter, may degenerate into the present form of the complaint. It is 
usually of very protracted duration. It seldom destroys life in 
children before the third or fourth month; though the chance ol 
a favorable termination, even under the most judicious treatment 



244 OF DIARRHCEA. 

after the disease has continued to this period, is generally very 
slender. So long, however, as the evacuations are free from pur- 
ulent matter, and the febrile irritation has not assumed a hectic 
character, there is still considerable probability of success from a 
judicious and persevering course of remedial management. I have 
seen several cases of recovery after the disease had run on, be- 
yond the sixth month. 

In the former variety of chronic diarrhoea, as has already been stat- 
ed the principal disease is seated in the stomach, small intestines, and 
liver, and consists more frequently of a high degree of irritability 
and irritation of these parts, than in actual inflammation-, though 
this latter form of disease is often ultimately superadded. In the 
present variety of the disease the principal affection is seated in 
the colon, and consists of chronic inflammation, with or without 
disorganization or ulceration in the mucous membrane of this por- 
tion of the intestinal canal. 

On post mortem examination, the mucous membrane of the colon, 
and ilium present distinct traces of inflammation. We sometimes 
discover a number of irregular patches of a fungoid appearance 
and of a dark or livid color, slightly elevated above the surround- 
ing parts. In other instances, small well defined ulcers with ele- 
vated margins, or extensive irregular ulcerations with ragged 
edges are met with. The coats of the intestines, particularly 
those of the colon, are sometimes thickened at the parts where 
these ulcers are situated; and in some instances, this thickening 
is so great as to diminish the area of the intestinal tube very 
considerably. Instead of ulcers the mucous membrane, occasion- 
ally exhibits a great number of small tuberculous elevation. The 
appearances just mentioned are in general most conspicuous about 
the lower portion of the colon. The mucous membrane of the 
small intestines, is usually very much injected, presenting here 
and there extensive patches of a bright red appearance. The 
stomach seldom presents any decided traces of disease. 

Treatment. — When diarrhoea has once acquired a chronic cha- 
racter, it is always of peculiarly difficult management. In the 
treatment of this form of diarrhoea, the attention must be directed, 
not so much to the mere diminution and suspension of the diarrhoeal 



OF DIARRHOEA. 245 

discharges, as to the removal of that fixed morbid condition of the 
stomach and bowels, upon which the excessive evacuations de- 
pend. The excessive irritability, the inflammation, and the func- 
tional disorder of the liver and intestinal exhalents are the objects 
against which our remedial measures must be principally directed. 
One of the most important requisites, to the successful treatment 
of chronic diarrhoea, is a total avoidance of every kind of stim- 
ulating or solid aliment. In the "weaning brash," this precau- 
tion is, perhaps, not so uniformly indispensable as in the ordinary 
chronic diarrhoea, attended with mucous inflammation and ulcer- 
ation of the colon. In this latter form of the complaint nothing 
can be effected without the strictest attention to this point. The 
nourishment must consist exclusively of thin mucilaginous fluids, 
such as gum-arabic water, barley water, very thin preparations of 
arrow-root, tapioca, sago, oatmeal gruel, and rice water. Not a 
particle of solid food, of any kind, should be allowed ; and the 
patient should guard particularly against overloading his stomach 
even with the mildest kinds of nourishment. I have often known 
the best directed course of remedial treatment, frustrated by a 
neglect of this important point of practice in such cases. Milk 
seldom answers well in this disease. It is apt to coagulate, and 
to pass through the bowels in an undigested condition, appearing 
in the evacuations in the form of small white flakes. This, of 
course, always increases the intestinal irritation, and aggravates 
the tormina and frequency of the discharges. Beef or chicken 
tea and thin broths are, in general, still more objectionable, as 
they rarely fail to increase the intestinal irritation and rapidity 
and painfulness of the evacuations. So far as my own observa- 
tion enables me to form an opinion, I am inclined to think that 
a very liquid preparation of tapioca, with infusion of slippery-elm 
bark for drink, forms the most appropriate artificial nourishment 
in cases of this kind. When the disease arises from weaning, 
however, nothing can be more appropriate and beneficial, than 
the mJk of a fresh and healthy nurse. Speedy restoration of the 
child to the breast, will often, of itself put a stop to " weaning 
brash." Should diarrhoea of an obstinate character occur, while 
the child is still nourished at the breast, and there is reason to 
suspect some unwholesome condition of the milk, a fresh nurse 



246 OF DIARRHCEA. 

should, if practicable, be immediately procured. Even artificial 
nourishment, such as gum-arabic water, or very thin preparations 
of tapioca or arrow-root, would under these circumstances be pref- 
erable to the continued use of the unwholesome milk, by which 
the disease was excited. It is well, however, not to be very pre- 
cipitate in separating the child from the breast in such cases; for, 
although it may be proper, and perfectly safe, to change the nurse 
when the quality of the milk is suspected, yet we ought to be well 
assured that this is actually the case, before the breast is entirely 
withheld, and the patient put on the exclusive use of artificial 
nourishment. Within the present year I was requested to con- 
sult in the case of an infant about nine months old, and not yet 
weaned. The child had been affected with diarrhoea, for more 
than four months. A variety of suitable remedies had been per- 
severingly used, but all to no purpose. We concluded to urge 
the immediate separation of the child from the breast, and to 
nourish it, exclusively with gum-arabic water, and thin tapioca. 
This was done, and under the use of this nourishment and minute 
doses of calomel and opium, the little patient was, in the course of 
about two weeks, freed from its dangerous malady. The treat- 
ment of chronic diarrhoea in children is often rendered extremely 
difficult and irksome, by the ignorance and perverse conduct of 
mothers and nurses. In despite of the most earnest injunctions to 
withhold every kind of nourishment but the simple mucilaginous 
fluids just mentioned, the little patient is often clandestinely sup- 
plied with what are deemed innocent delicacies, though in reality 
highly inappropriate and injurious. They cannot conceive that 
a " little soft cake," or a " bit of tender chicken," or some such 
article, could possibly do any harm. I have often been foiled in 
my efforts to cure cases of this kind, by this unwarrantable and 
pernicious departure from the directions that were given on this 
point; and the young practitioner ought to bear in mind, that 
unless this part of his curative plan is rigidly fulfilled, he can ex- 
pect nothing but disappointment and defeat in his attempts to 
arrest the progress of the malady.. 

During the early stage of weaning brash, the liver and alimen- 
tary canal appears to be in the same condition as in common 
bilious diarrhoea. The stools are of a green, somewhat slimy and 



OF DIARRHCEA. 247 

curdled appearance, accompanied with frequent nausea and oc- 
casional vomiting. The principal objects to be kept in view in 
prescribing for the complaint at this period, are to correct the 
functional derangement of the liver and to allay the morbid irri- 
tability and irritation of the stomach and bowels. In the com- 
mencement of the treatment the intestinal canal should be freely 
evacuated by a moderate dose of calomel followed, in three or 
four hours, by a full dose of castor oil. After the purge has ope- 
rated, the alimentary canal ought to be tranquillized by a suitable 
dose of laudanum or Dover's powder. To correct the morbid 
condition of the liver, and moderate the excessive irritability of 
the bowels, recourse must next be had to the regular exhibition of 
minute portions of calomel and opium. The fourth of a grain of 
the former with the twentieth of a grain of the latter, may be 
given three or four times daily, according to the age of the pa- 
tient and the urgency of the symptoms. After these powders 
have been used for two or three days, another dose of castor oil 
with a {ew drops of laudanum should be administered. The oc- 
casional exhibition of a mild laxative is proper and beneficial; but 
a frequent repetition of active purgatives is calculated to do much 
injury in cases of this kind; and after the disease has acquired a 
strictly chronic character, even the mildest purgative remedies 
must be employed with great caution. The calomel may be con- 
tinued until the bile becomes less abundant in the evacuations, 
and assumes a more natural appearance. It is to be observed, 
however, that in the employment of calomel, particular care is 
necessary lest it be carried to the extent of producing a decided 
mercurial action in the system — a result which is apt to give rise 
to very unpleasant consequences in children while dentition is 
going on. I have witnessed several very distressing instances of 
slaughing of the gums and general mercurial erethism, from the 
protracted use of calomel in chronic bowel complaints of chil- 
dren. When there are symptoms of acidity in the alimentary 
canal, alkaline and cretaceous remedies should be employed, 
along with the calomel and opium. From five to ten grains of 
prepared chalk, in union with half a grain of Dover's powder 
and a fourth of a grain of calomel, forms an excellent remedy in 



248 OF DIARRHCEA. 

such cases. The chalk may also be conveniently given in the 
form of a fluid mixture, thus: 

R Cret. ppt 3ii. 

Sacch. Albi. . . . 3i. 

Mucilag. G. Arab. . . gss. 

Tinct. Opii. . . . gtt. xx. 

Syrup Rhoei. . . . 3 U - 

Aq. fontanae . . . Jii. 

M. f. Of this a teaspoonful should be given every two or 
three hours. 

I have employed a solution of bicarbonate of soda, in a weak in- 
fusion of hops, with the happiest effect in this form of diarrhoea, 
when accompanied with acidity in the primas viae. At the same 
time that these remedies are employed, a stimulating plaster 
ought to be laid over the epigastrium, or frictions made with ru- 
befacient liniments. A plaster made by melting equal parts of 
burgundy pitch and common diachylon plaster, spread on a piece 
of sheep skin, forms an excellent application for this purpose. 
The spice plaster, mentioned under the head of chylous diarrhoea, 
may also be used with advantage. Under the employment of 
these means, in conjunction with the most rigid adherence to a 
bland mucilaginous diet, this form of diarrhoea may often be sub- 
dued without much difficulty, when encountered at an early pe- 
riod, or before inflammation or structural lesion has taken place 
in the affected parts. 

When the disease has acquired a strictly chronic character, and 
is accompanied with symptoms indicative of inflammation of the 
mucous membrane of the bowels, the treatment must be, in some 
degree, varied from that which has just been mentioned as appro- 
priate, while the local affection consists, as yet, of simple irrita- 
tion and functional derangement. The symptoms which indicate 
this aggravated state of the disease are; a frequent, quick, and 
sharp pulse, more especially towards evening, and an hour or two 
after eating; tenderness of the abdomen to pressure; small evac- 
uations consisting chiefly of mucus, streaked occasionally with 
blood, and containing, at times, small masses of a cream-like or 
purulent matter, or very watery discharges, of a reddish color, with 
a large quantity of flocculent mucus, resembling the washings of 
flesh; a red, raw, rough or glassy appearance of the tongue; urgent 



OF DIARRH(EA. 249 

thirst; extreme moroseness and fretfulness of temper; rapid ema- 
ciation; and occasional circumscribed flush on one cheek; draw- 
ing up the legs towards the abdomen when lying down; and a 
peculiarly contracted and anxious expression of the countenance. 
When these symptoms are present, there can be no doubt of the 
existence of chronic inflammation in some portion of the mucous 
membrane of the bowels; and when the evacuations are very fre- 
quent, watery and whitish, and the emaciation is extremely rapid, 
we may presume that the mesenteric glands, also, are in a state 
of disease. 

In this aggravated state of the disease, local depletion by leech- 
ing, and counter irritating applications are among the most useful 
remedies we possess. If leeches can be procured, two or three 
should be occasionally applied to the epigastrium, and a large 
emolient poultice laid over the abdomen after the leeches have 
been separated. Whether leeching be practised or not, active 
counter irritation ought never to be neglected in such cases. 
Very little, will be effected by internal remedies, without the 
concurrent aid of active irritating applications to the region of 
the affected organs. Blistering appears to me decidedly the best 
means of fulfilling this purpose. Pustulation with tartar emetic 
ointment, is apt to give rise to corroding and extremely painful 
ulcerations in infants. When the epispastic is properly managed 
it seldom occasions much suffering; and the derivative tendency 
of blistering is, probably, greater than that of any other applica- 
tion of this kind. The vesicatory shouJd be removed as soon as 
the skin is reddened or slightly inflamed, which usually occurs, in 
about three hours, and a soft emollient poultice laid over the part. 
In the course of a few hours a fine blister will be raised, which is 
then to be opened and dressed in the usual manner. I have been 
in the habit of dressing blisters, in cases of this kind, with weak 
mercurial ointment, omitting at the same time the internal use of 
calomel, and, as it appeared to me, often with obvious advantage. 
Calomel, even in minute doses, if long continued, sometimes pro- 
duces very unpleasant irritation, when the mucous membrane of the 
bowels is in a state of chronic inflammation. As the liver, how- 
ever, is always in a very disordered condition, mercurials are ob- 
viously indicated; and hence, the use of mercurial ointment in 

2K 



250 OF DIARRHOEA. 

the way just mentioned, doubtless has a very beneficial tendency in 
this affection. I have known the continued application of large 
emolient poultices over the abdomen, without blistering, or any 
other mode of counter-irritation, to produce excellent effects in 
cases of this kind. The poultice should be renewed three times 
daily; and before a fresh one is applied, the skin ought to be 
washed with warm water, and afterwards rubbed with flannel 
until it is dry and somewhat reddened. I am persuaded, from 
what I have witnessed, that a diligent course of management, in 
this way, is calculated to do a great deal of good — as much, pro- 
bably, as is usually derived from the more painful counter-irrita- 
ting applications. 

Among the internal remedies, opium, calomel, the sulphate of 
iron, and the nitrate of silver, appear to me the most valuable in 
this aggravated state of weaning brash. After the bowels have 
been gently evacuated by a dose of castor oil with a few drops of 
laudanum, small doses of calomel and opium should be given 
three or four times daily, until there is reason to think that the 
action of the liver has been improved. Much more caution is 
necessary in the use of calomel in this stage of the disease, than 
at an early period, before inflammation of the mucous membrane 
has taken place. When this tissue is in a state of chronic inflam- 
mation, calomel not only sometimes increases the local irritation, 
but is apt, when frequently used, to produce a general erethism 
of the system, which is always extremely unfavorable in its ten- 
dency. Calomel, indeed, can rarely have any direct beneficial 
operation upon the intestinal canal, Avhen its mucous coat is in a 
state of chronic inflammation. Its usefulness under these circum- 
stances depends on its well-known tendency to correct the morbid 
condition of the liver, and consequently to improve the vitiated 
or acrid biliary secretion. Opium may be very beneficially em- 
ployed, throughout the whole course of the disease. I have more 
frequently succeeded in arresting the disease, in this stage, by the 
internal use of small doses of opium and sulphate of iron, in con- 
junction with the external means mentioned above, than by any 
other remedy. After the morbid condition of the liver has been, 
in some degree, corrected by small doses of calomel and opium, 
the sulphate of iron may be very advantageously substituted for 



OF DIARRHOEA. 251 

the calomel. A powder composed of the twentieth of a grain 
of opium, the eighth of a grain of sulphate of iron, and five or 
six grains of powdered gum arabic, should be given three or four 
times daily according to the age of the child. Harsh and inappro- 
priate as the nitrate of silver may appear to be, in cases of this 
kind, I have, nevertheless, in a few instances, found its internal 
administration to produce the happiest effect. In an extremely 
severe case of chronic diarrhcea, which commenced in the usual 
way of weaning brash, and which was evidently attended with 
chronic inflammation, and, as it seemed to me, ulceration of the 
mucous membrane of the colon, I administered this article in union 
with laudanum, with prompt and decided benefit. One grain of 
the nitrate was dissolved in an ounce and a half of gum-arabic 
water, to which twenty drops of laudanum were added. A tea- 
spoonful of this solution was given three times daily. The dis- 
charges soon became less frequent and of a better appearance; 
and under the continued use of this remedy, together with blisters 
dressed with weak mercurial ointment, and the mildest possible 
nourishment, the disease gradually yielded, until it was finally 
entirely subdued. The patient was about eighteen months old. 
In several other instances of a similar character, this treatment 
was attended with unequivocal advantages; and I have never 
known the slightest inconvenience to result from the use of 
this article in chronic mucous inflammation of the bowels, when 
administered in a mucilaginous solution and in very small doses. 
In cases of this kind, the nourishment should consist exclusively 
of barley-water, a solution of gum arabic, infusion of slippery elm, 
the mucilage of iceland moss, and a very liquid preparation of 
arrow-root. The smallest portion of solid food, will generally do 
more harm, in a few hours, than can be remedied in several 
weeks. In this advanced stage of the disease, purgatives ought 
to be employed with the utmost degree of caution. Dr. Dewees 
advises that " small but repeated doses of castor oil should be 
given." I cannot but regard this advice as decidedly injudicious, 
and calculated, if followed up, to do much mischief. In ordinary 
cases of diarrhoea, depending on simple irritation from offensive 
substances lodged in the bowels, repeated purging is often indis- 
pensable. In such cases, the principal objects are — to remove 



252 OF DIARRH(EA. 

the irritating substances out of the bowels by laxatives, and to 
allay their inordinate irritability by opiates. In the present form 
of diarrhoea a very different state of things obtains. The mucous 
membrane of the bowels is inflamed, and perhaps ulcerated. The 
diarrheal discharges depend on this diseased condition of the 
intestines, rather than on the acrid secretions which are poured 
into them. It could hardly be expected therefore, that any ad- 
vantage would result, from frequently irritating the inflamed mu- 
cous membrane and urging the already too greatly excited peri- 
staltic action of the bowels, by purgatives. In the chronic diar- 
rhoea of adults, accompanied with mucous inflammation of the 
colon, no prudent and experienced physician, certainly, would 
resort to " repeated doses of castor oil." I have repeatedly wit- 
nessed the pernicious consequences of this practice in cases of this 
kind. I do not mean to object to the occasional administration of 
a moderate dose of castor oil with a few drops of laudanum. If 
the dose be repeated once every three or four days, and laxative 
enemata employed, during the intermediate periods, the bowels 
will be kept in sufficient motion to prevent the undue retention 
and accumulation of acrid secretions in them. 

It may be objected to the preceding observations, that if arti- 
cles so corrosive and active as lunar caustic, and the sulphate of 
iron, may be given with advantage in this complaint, no harm 
can be reasonably apprehended, from the mild impressions of 
castor oil, or other gentle purgatives. This argument, however, 
is not supported by experience. There is something very pecu- 
liar in the impressions made by these articles. The nitrate of 
silver, especially, though a highly active irritant, often exerts a 
peculiarly soothing and alterative effect on inflamed surfaces. In 
certain varieties of ophthalmia, this article is pre-eminently use- 
ful; yet were castor oil or rhubarb applied to the eye, the inflam- 
mation would, undoubtedly, be greatly increased. It is not the 
strength but the character of the irritant that renders it either 
salutary or hurtful in certain affections. Purgatives excite the 
intestinal nerves and increase the peristaltic action; lunar caustic 
and the sulphate of iron, not only excite, but change the sensibil- 
ity and irritability of the inflamed mucous membrane of the 



OF DIARRHCEA. 253 

bowels, and thus contribute essentially to the reduction of the 
inflammation. 

In the chronic diarrhoea of adults, the sulphate of copper, has, 
within the last four or five years, been employed in Europe with 
entire success. When the inflammation and ulceration is chiefly, 
if not wholly, confined to the colon, this article sometimes pro- 
duces a very good effect. I have used it in a few instances, of 
this kind, in adults, with unequivocal advantage. It is not im- 
probable that it might be used with equal benefit in the chronic 
diarrhoea of children — more especially in the second variety men- 
tioned in the former part of this section, and which does not dif- 
fer, in its pathological character, from the ordinary chronic diar- 
rhoea of adults. This modification of the complaint, as has already 
been observed, is generally the result of neglected or mismanaged 
acute diarrhoea, and is seldom met in very young infants. The 
stools are slimy, usually streaked with blood, often attended, with 
a slight feeling of tenesmus, or with considerable straining, and 
almost invariably conspicuously mixed with purulent matter. 
In such cases, besides the remedies already mentioned as ap- 
plicable in chronic diarrhoea, the sulphate of copper, may be 
tried. It should always be given with opium. The one tenth of 
a grain, with the fifteenth of a grain of opium, may be given every 
morning, noon, and evening; and the proportion of the sulphate 
ought to be gradually increased, until it is found to produce 
nausea or vomiting. The balsam copaiva, too, may sometimes 
be used with decided benefit in such cases. I have used this 
article repeatedly in the chronic bowel complaints of children, 
and occasionally with considerable advantage. It should be given 
in the form of emulsion and in union with small doses of lauda- 
num. Five or six drops of the balsam, with a drop or two of 
laudanum should be given three or four times daily. In cases of 
this kind I have seen much good done by a decoction of the con- 
ferva helminthocordon, I am satisfied that this is a valuable 
remedy in certain varieties of protracted diarrhoea. Where 
there is reason to suspect the presence of verminous irri- 
tation, this article is, probably, the most useful remedy we 
possess. It has, pretty active vermifuge powers, and by the small 
portion of iodine which it contains, may operate very beneficially 



254 OF DIARRHCEA. 

on the liver and mesenteric glands. Be this as it may, I have 
witnessed its good effects in several very long-standing cases, after 
various other remedies had been used without any manifest ad- 
vantage. Two drachms of the conferva should be boiled in half a 
pint of water, down to four ounces. The dose of this is a tea- 
spoonful three or four times daily, and I have usually added about 
a tenth of a grain of the sulphate of iron to each dose. Diarrhoea, 
of a very obstinate character, alternating, however, with occasional 
short periods of costiveness, sometimes arises from the presence of 
worms in the bowels. These cases are, almost without exception, 
attended with a tumid and hard state of the abdomen, slimy eva- 
cuations, a peculiarly offensive breath, a pale countenance, vora- 
cious appetite, and frequently with tumefaction of the upper lip. 
As instances of this kind are not necessarily, or even generally, 
connected with mucous inflammation of the bowels, recourse may 
be had to pink-root tea, or to small and repeated doses of calomel 
followed by an active purgative. My own experience, however, 
has led me to prefer a decoction of the helminthocordon, in cases 
depending, or connected with verminous irritation, to any other 
remedy 1 have tried. 

Astringent and cretaceous remedies are not, in general, calcu- 
lated to do good in chronic diarrhoea. When there is mucous in- 
flammation or ulceration present, they seldom fail to do manifest 
harm. After the local affection has been subdued, and the faecu- 
lent and copious diarrhoeal discharges result from weakness and 
relaxation of the bowels, vegetable astringents will sometimes 
operate very favorably. So long, however, as the evacuations are 
small, slimy, streaked with blood, or mixed with purulent matter, 
remedies of this kind are wholly inadmissible. During conval- 
escence, they may sometimes be proper; but very rarely, if ever, 
during the active stages of the disease. The blackberry root, or 
the root of geranium maculatum, are among the best, if not the 
very best astringents we have, for purposes of this kind. 



OF WORMS. 255 



CHAPTER XXI 



OF INTESTINAL WORMS. 



Concerning the origin of intestinal worms, much has been 
conjectured, but little ascertained. It is a subject, by no means 
unworthy of particular research; for beside the interest it pos- 
sesses in the eye of the naturalist, it has peculiar claims on the 
attention of the physician. An exact and complete knowledge 
of the sources and generation of these animals, might furnish ma- 
terials for a certain prophylactick mode of treatment. As the in- 
quiry, however, does not come properly within the design of this 
work, we will not enter into an extensive examination of the va- 
rious notions, that have, been started with respect to the forma- 
tion of worms, but briefly notice the two hypotheses, which are 
supported by the greatest number of probabilities. 

The first of these is framed in accordance with the ancient 
dogma, omnia ex ovo, and derives its principal evidence from the 
analogy of nature, and the inadequacy of any other mode for ex- 
plaining the origin of intestinal worms. According to this notion, 
these animals are evolved from ovula, received into the stomach 
and bowels from without, along with the food and drink. It 
may be remarked, that the theory necessarily involves the suppo- 
sition of the existence without the body of worms, by which 
these ova are generated, and which are similar to intestinal 
worms. But the most accurate observation is in contradiction to 
this supposition. The few earth-worms, resembling tcenia and 
ascarides, are of very rare occurrence and only to be met with 
in certain localities; whereas these species of vermin are common 
both to man and the inferior animals, in all countries and every 
variety of situation. Linnaeus, Gmelin and a few others report, 
indeed, that they have discovered similar worms in stagnant wa- 
ters and marshes; but the ablest helminthologists of the present 



256 OF WORMS, 

day, assert, that they are quite dissimilar, in structure and habits, 
to those generated in the intestines of animals. Moreover, intes- 
tinal worms, when expelled from the body, and exposed to the 
air or placed in water, almost immediately die — a circumstance 
hardly to be looked for, if originally derived from without. Fi- 
nally, it is ascertained, that earth-worms and such as live in water, 
do not change their forms or characters, when accidentally received 
into the alimentary canal. Instances have been mentioned, of 
various aquatic animals being taken into the stomach, where 
they have thriven so wonderfully as hardly to be recognized as 
individuals of the different species to which they naturally be- 
longed. In all these cases, however, the change was in their 
magnitude, not in their structure and essential nature. These 
facts go to prove that intestinal worms constitute an entirely dis- 
tinct species from all others, and it therefore, becomes rather a 
perplexing task, for the advocates of the ovular theory, to point 
out the sources whence the verminous ova are derived. 

But there are other difficulties in the way of this hypothesis. 
Cases, on the best authority, are recorded of worms found in the 
intestines of foetuses, and of infants newly born. Kerkringius dis- 
covered lumbrici in the stomach of a seventh month foetus: in 
another instance, he found a great number of small worms in the 
bowels of a child, just after birth. A tape worm, as Pallas states, 
was found, by Brendel, in the intestines of a newly-born infant; 
and according to the testimony of Block, Hains met with a simi- 
lar instance. Taenia have been discovered in the bowels of a 
pup, immediately after birth, as in the case stated by Rudolphi 
to have occurred undgr the notice of the celebrated Blumenbach. 
It is also on record, that a fasciola hepatica was detected in a 
lamb still in utero. The fact, too, that hydatids and other ani- 
mals are not unfrequently met with in parts of the body, that can 
have no communication outwardly, discountenances the ovular 
hypothesis. 

A view of these difficulties has contributed to turn the atten- 
tion of many ingenious men to the doctrine of the spontaneous 
generation of worms within the body. This doctrine is chiefly 
sustained by the facts we have just mentioned, as militating 
against the notion of verminous generation from extrinsic ova. 



OF WORMS. 257 

That the ovula of worms should be transmitted through the 
medium of the ingesta, Dr. Bremser thinks altogether improbable. 
An experiment, performed by Schreiber, is also adduced by him 
in support of the hypothesis of spontaneous formation. A pole- 
cat was fed for six weeks upon milk, containing the eggs and 
various species of intestinal worms. The animal being killed at 
the end of that period, to the astonishment of all, not a single 
worm could be detected in his body. 

The advocates of the ovular theory, in attempting to obviate 
the difficulties that beset their opinions, and to combat the 
adverse hypothesis, contend, that there is no improbability in 
supposing, there may be a transmission of eggs through the 
medium of air, food and drink. As to Schreiber's experiment, 
they deem it quite inconclusive. Other circumstances, beside 
the mere presence of the ova, are necessary to the formation of 
worms. The intestines must -be so debilitated or disordered, that 
they shall be unable to destroy and cast off these parasitic 
animals. Now in the experiment related, the stomach of the 
pole-cat was in its usual healthy condition — at least there is no 
reason to believe otherwise. It is further remarked, there are 
positive experiments to prove that worms may be propagated in 
the human body. Pallas, by a small incision, introduced into 
the cavity of a dog's abdomen, the ova of tasnia, from the bowels 
of another dog. At the end of a month young tasnia were 
thriving in the cavity. In this case, they were not checked in 
their developement, by the active powers of the alimentary canal, 
nor liable to be thrown off by its healthful motions. The case of 
hydatids and other animals, found in the close cavities of the 
body, is acknowledged to present considerable difficulties — not so 
many, however, it is said, as surround the hypothesis of a sponta- 
neous formation. Besides, it is quite possible, they remark, that 
the eggs from which these verminous animals are generated, after 
being received into the system, may, from their extreme minute- 
ness, have been taken up and carried away by the absorbents, to 
the different parts of the body, where they are found in their 
developement. The same remark is applicable to instances of 
worms discovered in foetuses. Owing to the intimate communica- 
tion established between the mother and the child, in utero, the 

2 L 



258 OF WORMS. 

diseases of the parent not unfrequently become the diseases of her 
offspring — and peculiarities of physical and moral constitution are 
also transmitted. Why then, it is asked, may not the ovula of 
worms, received into the system of the mother, be taken up by 
the absorbent vessels, and after passing into the circulation, be 
ultimately deposited in the bowels of the foetus? The difficulty, 
growing out of the distinct specific nature of intestinal worms, they 
attempt to lessen, by supposing, that a change in situation and 
mode of living may so far alter the external appearance of these 
worms, as to conceal their real character. 

Such are the principal grounds, upon which the two hypotheses 
stand. I will leave the student to make up his own opinion on 
the subject, with a single remark in particular reference to the no- 
tion of a spontaneous formation. It appears to me that an erro- 
neous sentiment of religion and the force of long-received opinions, 
— in other words, that partial views of the economy of nature, as 
also an undue deference to authority, — have exerted too much in- 
fluence over the enquiries of men, touching this subject. The 
ancient dogma, omnia ex ovo, unquestionably true in the general, 
is deemed by some universally so; although it is manifest it should 
not be extended beyond the experience upon which it is based. 
If then, certain remarkable phenomena should be observed, by no 
means in accordance with the general theory, analogy should not 
be a sufficient reason to make us doubt the evidence of our senses, 
and believe in opposition to facts, that such exceptions are not 
real, but apparent. 

Species of Intestinal Worms. — There are five distinct spe- 
cies of intestinal worms. 

1. The tricocephalus dispar — ( Trichuris — tricocephalus hominis, — 
ascaris trichuria ). — This worm, called by the English the long 
threadworm, is from an inch and a half to about two inches in length. 
About two thirds of its length is as thin as a horse hair, the 
remaining and posterior part being considerably thicker, termin- 
ating in a rounded or blunt extremity. The thin part is trans- 
versely striated; and the alimentary canal may be seen, by means 
of a lens, running from its thinner extremity in a direct line 
through the centre, into the thick posterior portion, where it 



OF worms. 259 

assumes a flat and spiral form. These worms are seldom nu- 
merous, and are principally found in the coecum. They have been 
discovered in the rectum, and some say they have met with them 
in the jejunum. 

2. Ascaris vcrmicularis. — (Oxyuris vcrmicularis — -fusaria vermi- 
cularis — mane or thread worm). — This is a very small white worm 
— the male being not above two lines in length, with a rounded 
or blunt extremity anteriorly, tapering to a point posteriorly. 
The female is considerably larger, being from four to five lines 
in length, terminating in an extremely fine extremity posteriorly, 
resembling the point of the finest needle. These worms are found 
only in the large intestines, and principally in the lower part of 
the rectum, where they are often congregated in almost countless 
numbers. The reports, that have been made, of their existence 
at times in the ventricles of the brain may be justly discredited. 

3. Ascaris lwmbricoid.es. — (Fusaria lumbricoides — lumbricusteres). 
These worms are from two or three to ten or twelve inches in 
length, round, of a yellowish white or brownish-red color, of 
nearly a uniform thickness, except at the extremities; which taper 
to a blunt point. They are from two to three lines in thickness. 
The head may be distinguished by a circular depression within a 
line of one of the extremities, terminating in three small tuberos- 
ities or valves, which the worm has the power of opening or clos- 
ing. When they are opened, a very minute patulous projection 
may be seen, which constitutes the mouth of the worm. A very 
small groove passes longitudinally from one extremity to the other, 
on both sides. The alimentary canal terminates in a transverse 
depression on the under surface, near the posterior extremity. 
The male is smaller than the female, and may be distinguished by 
its shortly curved caudal extremity. In some instances the organ? 
of generation are conspicuous — consisting of two small cylindrical 
projections in the curved part of the tail. These worms inhabit 
the small intestines, and occasionally ascend into the stomach. 
It is said, too, that they have been discovered in the gall bladder 
and common bile duct. 

4. Tania lata. — (Bothriscephalus latus — tcenia membranacea — t. 
vulgaris). — This worm often acquires a very great length, — from 
thirty to forty feet and more. It is from four to ten lines in 



260 OF WORMS. 

breadth, flat, white, and composed of a series of concatenated 
joints, resembling a piece of white tape. The head is armed with 
two processes, by which the worm attaches itself to the intestines. It 
inhabits the upper portion of the bowels and the stomach. Three or 
four of these worms sometimes exist in the same person. Where 
they prevail, the taenia solium is seldom met with. 

5. Tcenia solium. — (Tcenia cucurbitini — t. osculis margin-albius.) 
This worm is rarely, if ever, voided whole. It is passed off in 
pieces of a greater or less number of joints, or in single joints, 
bearing considerable resemblance to the seeds of gourd. Pieces, 
however, upwards of twenty feet in length, have been discharged, 
although generally not more than three or four joints, pass off to- 
gether. The anterior part tapers off into a very fine, thread 
like extremity, the head being extremely small, and furnished at 
its sides with four small apertures (pscula). This is the most com- 
mon species of tape-worm, and like the taenia lata, inhabits the 
stomach and small intestines. The name would indicate that one 
worm alone inhabited the bowels of the same individual; but this 
is not so, two or three frequently being voided by the same 
person. 

Circumstances, favoring the generation of intestinal worms. — Al- 
though unenlightened with regard to the origin of these parasitic 
animals, observation has revealed to us many of the circumstan- 
ces, that favor their production and increase. The principal of 
these are, a general debility of the system, and a feeble or de- 
ranged condition of the alimentary canal. Whatever, therefore, 
disposes to these states, constitutes a remote cause of worms, — 
such as, too rapid growth; scrofula; a sedentary and an inactive 
mode of life; habitual exposure to a damp atmosphere; indul- 
gence in crude, unripe fruits; the abundant use of fat, and farina- 
ceous articles of diet, and of fresh milk; the ingestion of more 
food than the stomach will readily digest, or than is necessary to 
the wholesome sustenance of the system. Dr. Bremser asserts, 
that all esculent articles, containing an abundant proportion of 
nutritive matter, will when taken in quantities more than suffi- 
cient to minister to the necessities of life; greatly favor the form- 



OF WORMS. 261 

ation of worms. Sugar by some has been thought to aid largely 
in the development of these animals; but this has been denied by 
others who have enjoyed equal opportunities of correct obser- 
vation. 

That verminous diseases have ever prevailed as epidemics, is, 
by some, denied and not unfrequently ridiculed. Why the state- 
ment should have excited ridicule, we are at a loss to discover; 
since there certainly can be no absurdity in the notion, that pecu- 
liar atmospheric conditions may at times prevail throughout large 
districts of country, affecting the intestinal canal in such a man- 
ner, as shall particularly dispose it to favor the generation of 
worms. Besides, if the concurrent testimony of many very emi- 
nent authorities is to be believed, we shall be obliged to admit the 
actual occurrence of such epidemics. A very remarkable instance 
of this kind is related by Marie, which occurred at Ravenna and 
the surrounding district. Block has also given an account of an 
epidemic worm-fever. 

In some countries, verminous affections prevail far more than 
in others. In Savoy and Chambray intestinal worms are said to 
be remarkably common in all classes of society, (Daquin, Brem- 
ser,) and the same observation has been repeatedly made of Hol- 
land and Switzerland. The prevalence of verminous disease, in 
the latter country is ascribed by Bremser to the abundant use of 
milk and cheese. Nevertheless we may be said to be ignorant 
of the various circumstances that occasion the spread of these dis- 
eases in particular districts. Holland, in climate and situation, 
differs entirely from Switzerland, being low, flat, moist and marshy; 
and moreover, fish enters largely into the diet of the inhabitants. 
Still we find the Swiss peasant, living amidst rugged Alps, and 
"breathing the difficult air of the iced mountain's top," equally lia- 
ble with the Hollander to verminous complaints. It is thought 
by some that worms are more prevalent in cities than in the 
country; and Pallas believes that carnivorous animals are more 
subject to them than those of the graminivorous sort. Bremser 
states on the other hand, that it is no unfrequent circumstance to 
find large numbers of worms in the intestines of those animals, 
that subsist principally on vegetables. The greater prevalence 
of verminous affections in cities, is attributed, by him, to the larger 



262 OF WORMS. 

proportions of causes, tending to enfeeble or deprave the general 
system, and derange the digestive functions — such as impure air, 
deficient exercise, luxurious living and irregular habits. It has 
already been remarked that an over nutritious diet tends to pro- 
duce worms, but a deficiency of nutriment would not seem to 
occasion the same result. 

Different districts of country are liable to the prevalence of 
different species of worms. The occurrence of the tape-worm is 
particularly common both in Switzerland and Holland; and it is 
worthy of remark, that, in the former country, the bothriocepha- 
lus latus is by far the most frequently met with. In Germany, 
the greater part of France, in Italy and even in the Tyrol, the 
taenia solium is almost the only species of tape-worm to be found. 
In Sweden, according to Rhudolphi, the broad tape-worm occurs 
but rarely, but the taenia solium is of frequent occurrence. This 
latter species prevails also most frequently in Great Britain, 
although the former sort is not seldom met with. (Rhind.) The 
Guinea worm, infesting the sub-cutaneous cellular tissue, is con- 
fined to tropical countries: although brought into the temperate 
regions, by persons afflicted with it, it has never there become a 
prevailing affection. 

Childhood is the period of life, especially subject to vermin- 
ous disease. The tape-worm, however, is generally the pest of 
riper years. As a general rule, those children, who are confined 
altogether to their mother's milk, suffer least from worms. Dr. 
Dewees declares, that he has never seen worms in children under 
ten months of age, and only in two instances of that age, both of 
whom were weaned at four months. 

Symptoms. — The symptoms, arising from verminous irritation, 
are as numerous and diverse, as the sympathies that subsist 
between the alimentary canal and the different parts of the body. 
It is on account of the variety and complexity of these sympa- 
thies, and because we have no certain means of indicating the 
specific marks of verminous irritation, that the symptomatology 
of worms is so imperfect. The only sure indication of their 
existence, is their appearance in the evacuations. Nevertheless, 
there are many symptoms that will lead the judicious practitioner 



OF WORMS. 263 

to suspect their presence and prescribe accordingly. The coun- 
tenance is pale and leaden-colored, with occasional flushes, or a 
circumscribed spot of red in one or both cheeks; the eyes become 
dull; the pupils dilate; an azure semicircle runs along the lower 
eye-lid; the nose is irritated, swells and sometimes bleeds; there 
is tumefaction of the upper lip; occasional head-ache, with hum- 
ming or throbbing in the ears; an unusual secretion of saliva; 
slimy or furred tongue; breath very foul, particularly in the 
morning; appetite variable, — sometimes voracious, with a gnaw- 
ing sensation of the stomach; at others, entirely gone; fleeting 
pains in the stomach; occasional nausea and vomiting, the matter 
thrown up, being limpid like water; violent tormina through- 
out the abdomen, particularly about the umbilical region; bow- 
els irregular — at times costive, and then disposed to frequent 
dejections; stools slimy, not unfrequently tinged with blood; belly 
swollen and hard, attended with emaciation of other parts of the 
body; urine turbid, yellowish or — after depositing a sediment, 
has the appearance of milk and water, (Rhind); respiration, 
occasionally difficult and accompanied by hiccough ; sometimes 
cough, dry and convulsive, stertorous or suffocating; uneasy and 
disturbed sleep, with grinding of the teeth; temper variable, but 
generally irritable. Of all these, the most infallible symptoms 
are by some supposed to be, unusual enlargement of the pupil; 
voracious appetite; inordinate secretion of saliva; emaciation- 
pricking sensation of the stomach; swelling and hardness of the 
abdomen, and loathing of food. Nevertheless, all these symptoms 
may arise from other affections. According to Rosenstein, the 
surest indication of their presence, is the uncomfortable sensation 
experienced by the patient after a draught of cold water, and 
voiding some worms or fragments of worms. There can, of 
course, be no doubt as to the infallibility of the latter symptom. 

It has been fancied by some persons, that worms perform very 
wholesome offices in the animal economy, consuming the super- 
abundant nutriment, destroying morbid secretions, and stimulating 
the intestines to the expulsion of ungenial substances. But daily 
experience and correct observation teach, that these are but 
imaginary benefits, whilst the evils they inflict are exceedingly 
mischievous and almost inevitable. Undoubtedly it may have 



■264 OF WORMS. 

happened, that many disorders have, without any foundation, 
been ascribed to verminous irritation; for the etiology of disease 
is by no means a certain science. Besides, the same condition of 
the intestinal canal, that favors the generation of worms, may be 
the principal source of many of the complaints, co-existent with 
the presence of these animals. That verminous irritation, how- 
ever, is sometimes the direct and exclusive exciting cause of 
severe and dangerous disorders, we may not disbelieve. Chorea, 
epilepsy, hydrocephalus, emaciation, convulsions, paralysis, fevers, 
dropsy, mania, and a vast variety of anomalous affections, are 
at times the immediate consequences of verminous irritation, 
and frequently disappear after the expulsion of the worms. 
Esquirol knew eleven persons cured of mania by the expulsion 
of a large number of lumbrici. Brera states, that a lumbricoi- 
des in the urinary bladder, produced nephritis and fatal disease 
of the bladder. The same author narrates, a case in which 
pains in the joints, similar to those of arthritic rheumatism, were 
occasioned by worms in the intestinal canal. The pains immedi- 
ately ceased upon the expulsion of nine large lumbricoides. The 
presence of worms sometimes induces singular idiosyncrasies. 
An instance is recorded of a patient, afflicted with taenia and 
ascarides, to whom the sound of music, instrumental or vocal, 
was quite intolerable. Another case is related, where a person, 
in a convulsive fit from verminous irritation, heard by accident 
some musical sounds, and was immediately cured. 

Treatment. — In prescribing for intestinal worms, we should 
have strict regard to the regimen, confining the patient to a 
spare and liquid diet, and exhibiting two or three mild purga- 
tives, a few days previous to the administration of anthelmintic 
remedies. These preparatory measures are calculated to secure 
success more frequently, from the employment of the ordinary 
vermifuges. 

hamhricoid. — My own plan of management for the expulsion of 
the long round worm, is to put the patient on a liquid diet, and to 
order him a small dose of epsom salts every morning for three or 
four days. On the fourth morning, I direct a decoction of the 



OF WORMS. 265 

root of spigelia, in the proportion of an ounce of the root to a 
pint of water, boiled down to a half pint. This, being sweet- 
ened, is to be drunk in the course of three or four hours, by a 
child of from five to ten years old, commencing in the morning 
after having taken a little milk and water into the stomach. As 
soon as the whole of the decoction is taken, an active dose of 
calomel and jalap is to be administered, or a dose of castor oil 
and turpentine, in the proportion of half an ounce of the former 
to two drachms of the latter, given in doses corresponding to the 
age of the patient. I have rarely failed by this plan, to procure 
the discharge of worms, where they existed in the bowels. The 
remedies and modes of treatment, recommended for the expulsion 
of this species of worms, are almost innumerable. A few of them 
deserve our attention. According toBremser,the electuary append- 
ed below* is highly efficacious as a vermifuge. It is to be given 
to a child in doses of a teaspoonful, every morning and evening for 
six or seven days. I have used this electuary in four or five cases, 
with complete success. Exhibited to such an extent as to pro- 
duce frequent and watery evacuations, it does far less good, than 
when managed so as to procure three or four consistent stools 
daily. The empyreumatic oil of Chabertt has obtained great cele- 
brity in Europe for its anthelmintic properties, especially in 
respect to taenia, and is indeed universally used on that continent. 
Bremser and Brera speak very highly of its virtues, and Rudolphi 
asserts, that it is decidedly the most efficacious vermifuge we pos- 
sess. Fifteen or twenty drops may be taken three or four times 
daily, by children from two to seven years old. Small doses of 



* Sen. Santonic. • « ss _ 

Pulv. root valerian ^ii. 

« " Jalapae 3ss— Bii. 

Snlphat. Potassae >7i ss -tjj 

Oxytnel. Scillit q, s# 

utfiat electuar. M. 

f This oil is made by mixing one part of the fetid spirits of hartshorn with three parts 
of the spirits of turpentine, and suffering them to digest for four days. The mixture is 
then to be put in a glass retort, and distilled in a sand bath, until three fourths of the 
whole have passed over into the receiver. This is to be kept for use in small and well 
closed phials. 

2M 



266 0F WORMS. 

calomel, with the powdered roots of spigelia and valerian, may 
be employed with advantage. Calomel, however, given in this 
way, is apt to produce ptyalism, especially as it is necessary to 
continue its use for several days, to insure its anthelmintic action. 
The chenopodium anthelminticum is well known in this country, 
as a vermifuge. By means of syrup, an electuary is sometimes 
made of the powdered seeds, and given, in doses of a tablespoon- 
ful, to a child of from two to five years old, twice a day — care be- 
ing taken to abstain from food several hours. It is generally 
necessary to repeat the dose four or five days. Beside these arti- 
cles, the most efficacious medicines, for the destruction and expul- 
sion of the round worm, are — sem. santonic; garlic; conferva 
helminthocordon; spirits of turpentine; geoffrea surinamensis; 
camphor; the green rind of unripe walnuts, and tin filings. 

The expulsion of lumbrici is not, in general, a very difficult 
task. But to accomplish this desirable object completely, we 
should persist for a considerable time in the use of anthelmintic 
remedies, so as not only to destroy the already existing worms, 
but the eggs containing the germs of others. Their expulsion 
being effected, strict regard should now be paid to preventing a 
reproduction of them. In view of this object, the patient should 
attend particularly to his diet, living abstemiously on plain food. 
A free indulgence in. saccharine matter, in milk, cheese, or but- 
ter, must be forbidden. Animal food ought to enter largely into 
the diet. Whatever tends to invigorate the general system, and 
bestow a wholesome energy on the stomach, should be carefully 
enjoined. Recourse must be had to tonics, particularly chalybe- 
ates, in conjunction with minute doses of aloes. A strong decoc- 
tion of the helminthocordon has appeared to me, not only valua- 
ble as a vermifuge, but particularly so, as a corrective of that 
deranged and debilitated condition cf the alimentary canal, favor- 
ing the production of worms. An ounce of this marine vegetable, 
with a drachm of valerian, should be boiled in a pint of water 
down to one gill. Of this a teaspoonful may be given every 
morning, noon and evening, with peculiar advantage. I have 
known several instances, in which children, apparently suffering 
from verminous irritation, were restored to perfect health by the 
use of this remedy, without any appearance of worms in their ex- 



OF WORMS. 267 

cretions. It is particularly beneficial in cases attended with the 
usual symptoms of worms, connected with want of appetite and 
mucous diarrhoea, which arise from mere debility of the digestive 
organs and a vitiation of the secretion of the bowels. 

Ascarides.— These worms, in general, are extremely annoying. 
From their being involved in the folds at the lower part of 
the rectum, they frequently give rise to inflammation of the anus, 
tenesmus or haemorrhoids. During the day, they are seldom a 
source of much uneasiness; but towards evening, and especially 
after lying down, they occasion a tormenting, an almost insup- 
portable irritation and titillation about the anus. So distressing 
indeed is the irritation, that nervous children arc not unfrequently 
thrown into convulsions thereby. In females, they sometimes 
pass into the vagina, giving rise to extreme uneasiness. Doctor 
Bremser states, that he knew a case of nymphomania, occasioned 
by their presence in that passage. They have also been known 
to enter the bladder and-urinary passages. They are generally 
more troublesome in damp than in dry weather. 

The complete removal of these worms is a work of great diffi- 
culty. They are so wonderfully reproductive, that no matter 
though thousands be brought away, we may soon have to recom- 
mence our task. The ordinary vermifuges, too, are of little avail in 
the destruction of ascarides. Their action is more particularly ex- 
erted upon the upper portions of the intestinal tube, and at all 
events lose their virtues before they arrive at the location of these 
animals. Even the most active cathartics are insufficient to expel 
them. Aloes, however, from the peculiar influence it exerts over 
the lower portion of the bowels, frequently causes their expulsion 
in large quantities, especially if assisted by the action of proper 
enemata. My usual mode of proceeding for the removal of these 
troublesome worms, is to prescribe three or four aloetic purga- 
tives every second day, together with two or three enemata, com- 
posed of a mixture of lime-water and milk, in equal proportions, 
daily. Injections of a solution of aloes, or of infusions of any of the 
abovenamed vegetable anthelmintics, will generally succeed in 
bringing away great numbers of these little animals. In a few 
instances, I have procured their expulsion in large quantities, by 
injections, composed of spirits of turpentine, mixed with milk, in 



268 OF WORMS. 

the proportion of a teaspoonful of the former to a gill of the latter. 
Injections of any of the common oils will oftentimes soothe the 
extreme irritation, and also destroy the worms. According to 
Nil Rozen, a drachm of refined sugar, dissolved in warm milk, 
has been injected with great success. Another remedy, highly 
spoken of, is a bougie, smeared over with mercurial ointment, 
and introduced into the rectum. Dr. Vanvert asserts, that flowers 
of sulphur, taken in the morning on an empty stomach, is one of 
the most efficacious remedies for the destruction and expulsion of 
ascaridies. In obstinate cases, the fumes of tobacco, or an infusion 
of the male fern, has been recommended by Dr. Bremser. When 
these worms have crept into the vagina, the same author states, 
that injections of cold water, with a small portion of vinegar, is 
the best remedy we possess. 

As taenia occur chiefly in the adult, their treatment does not 
come properly under notice in this work. 



OF OPHTHALMIA. 269 



CHAPTER XXII 



OF OPHTHALMIA. 



Purulent Ophthalmia. — The purulent ophthalmia of infants, 
generally commences between the fourth and eighth day after 
birth, though instances of its coming on at a more advanced 
period are occasionally met with. At first the eye-lids are ob- 
served to be glued together, in the morning attended with slight 
swelling and external redness. If the lid is raised, so as to expose 
its conjunctional surface, it is found of a uniformly red and 
slightly thickened appearance. As the disease proceeds, the swel- 
ling of the eye-lids increases; a thick purulent matter begins to 
issue from the eyes; the child becomes fretful and uneasy, and 
manifests much intolerance of light, keeping its eyes constantly 
and firmly closed. In the course of three or four days the con- 
junctiva becomes highly inflamed and cedematous — rising up 
around the cornea, so as almost to conceal it, or causing it to 
appear as if it were sunk deep into the eye. The secretion of 
pus is now extremely copious, and being confined under the swol- 
len and firmly closed lids, it bursts forth, from time <o time, and 
runs down the cheeks in large drops. If the disease be not arrest- 
ed, the lids become distended to the utmost degree, giving rise, 
sometimes, to eversion and consequent bulging out, or protrusion 
of the inflamed and highly infiltrated conjunctiva. The cornea, also, 
has by this time become implicated, and is more or less opake. 
Should the disease continue, corneal ulceration and' sloughing takes 
place, the aqueous humor escapes, and a total destruction of the 
organ ensues. Mr. Guthrie states that there are two varieties of 
infantile, purulent ophthalmia. In one, the inflammation is seated 
almost exclusively, in the conjunctiva of the lids; whilst in the 
other variety, the conjunctiva of the eye-ball is equally implicated 
in the disease. I have repeatedly noticed these diversities in the 



270 OF OPHTHALMIA. 

suppurative ophthalmia of infants. When the inflammation is 
confined to the lids, the disease seldom leads to any very serious 
injury to the eye; but it is, in general, quite as obstinate, and diffi- 
cult to be subdued as the latter variety of the complaint. 

The exciting cause of the suppurative ophthalmia of infants 
appears to consist of some acrid or morbid secretion in the vagina 
of the mother, applied to the infant's eyes during its passage from 
the womb into external life. I have never met with an instance 
of this disease, where upon enquiry I did not learn that the 
mother was affected with leucorrhoea or some other morbid vag- 
inal secretion. The tendency of gonorrhoeal matter, when 
applied to the eyes, to excite purulent ophthalmia is well known: 
and I have witnessed some striking examples of the same effect, 
from the application of leucorrhoeal to the eyes, in adults. The 
fact, too, that the matter discharged from the eyes in cases of 
this kind, is capable of producing the same disease when applied 
to the eyes of others, furnishes strong testimony in favor of this 
etiology of the disease. Mr. Ryall, whose opportunities for obser- 
vation on this subject have been very extensive, states, that he 
has frequently known purulent ophthalmia excited in nurses, " by 
the accidental application of the matter from the infant's eyes to 
their own." The time of its occurrence, also, affords some evi- 
dence of its dependence on a cause, connected in some way or 
other with the birth of the infant. If the disease were excited by 
intestinal irritation from bile and sordes in the alimentary canal, 
as some have supposed, it would, doubtless occur at every stage 
of infancy; whereas, its occurrence is almost universally confined 
to the two first weeks after birth, and in a vast majority of cases, 
comes on as early as the fourth day. This disease has also been 
ascribed to the "too early and unguarded admission of light and 
heat to the eyes of the new-born infant."* The great and sudden 
transition from the darkness of the womb to the external light, 
from the contact of the bland and congenial liquor amnii, to that 
of the atmospheric air, may, perhaps, at times operate injuriously 
on the tender eyes of the infant. It may be observed, however, 
that the good and all-wise author of nature, has endowed every 

* Edin. Med. and Surg. Journal, vol. 4. p. 247. 



OF OPHTHALMIA. 271 

creature with a capacity to accommodate itself to the inevitable 
changes and transitions, which it is destined to undergo, in the 
regular progress of its development, and it seems inconsistent with 
the perfect adaptation of the appointments of Providence that the 
new-born infant should be liable to serious inconvenience or injury 
from this cause. It cannot be doubted, indeed that unnecessary 
exposure of the infant's eyes, to a bright and heated light, may 
do much mischief. The practice of taking the infant, as soon as 
it is born, before a blazing fire, with perhaps a candle at no great 
distance, and keeping it "in this situation, not only during the time 
necessary for dressing, but often, long after this task is performed, 
lying on its side, on the nurse's knees, and with the face turned to 
the fire," is unquestionably very improper, and may be the source 
of much injury to the eyes. 

Treatment. — Whenever there is reason to suspect the existence of 
some morbid vaginal secretion, more especially gonorrhceal, on the 
part of the mother, the infant's eyes ought to be immediately wash- 
ed, in the most careful manner with tepid water. The water 
should be frequently changed and freely applied, so as to ensure 
the entire removal of the irritating matter that may adhere to the 
eyes. In all instances, care should, also, be taken, that the in- 
fant's eyes be not immediately exposed to a very strong licdit; 
for, although this may not, of itself, be capable of exciting this 
disease, there can be no doubt of its tendency to irritate the 
eyes, and to favor the occurrence of inflammation from other 
causes. By these precautionary measures, the disease may often 
be prevented, even where the most active virus has been applied 
to the eyes during the birth of the infant. 

As the inflammation, in this affection is always very violent 
and rapid, the treatment during the early stage must be strictly 
and actively antiphlogistic. If leeches can be procured, two or 
three should be applied to the external angle or on the under lid 
of each eye; and the bleeding from the leech-bites should, after- 
wards, be promoted by warm fomentations or by the application 
of a soft emolient poultice over the eyes. The child should be 
kept in a dark room, and when the blood has ceased to ooze from 
the leech-wounds, the poultice and bandages must be removed, 



272 OF OPHTHALMIA. 

and a thin and soft piece of linen, constantly kept moist with 
a weak solution of the sugar of lead, laid over the eyes. The 
eye-lids must be prevented from adhering to each other, by 
washing the tarsi frequently with tepid water, or with thin mu- 
cilage of quince seed or of the pith of sassafras. If this be not 
attended to, and the pus be suffered to remain confined under the 
closed and adhering lids, the risk of blindness, from corneal 
opacity, or a total destruction of the eye will be greatly increased. 
Bland and tepid fluids should, from time to time, be cautiously 
injected under the lids, to wash away the purulent secretion; and 
for this purpose, a weak decoction of poppy heads, or the muci- 
laginous fluids just mentioned, or tepid milk and water are most 
suitable. The bowels should be freely moved by small doses of 
calomel, in union with ipecacuanna, or pulvis antimonialis, with 
an occasional dose of castor oil. A powder composed of one 
fourth of a grain of calomel and one grain of the pulvis antimo- 
nialis or a half a grain of ipecacuanna may be given four times 
daily. If these do not keep the bowels sufficiently loose," a tea- 
spoonful of castor oil should be given, once daily, so as to procure 
four or five evacuations every twenty-four hours. The addition of 
antimonial powder to the calomel, has appeared to me peculiarly 
beneficial in such cases. The nausea and vomiting which is apt 
to follow the use of this mixture appears, frequently to do much 
good. Indeed the occasional administration of a gentle emetic in 
the early stage of the complaint, sometimes proves decidedly ben- 
eficial. I have, in several instances known immediate and very 
obvious benefit to result from the operation of an emetic dose of 
antimonial wine. 

If in the course of about thirty-six hours the violence of the . 
inflammation be not moderated, the leeching ought to be repeat- 
ed. During the active period of the inflammation emolient fo- 
mentations, such as warm water, or infusion of white poppy heads, 
will assist in mitigating the pain, and local irritation: but, with 
the exception of a very weak solution of sugar of lead, all astrin- 
gent and stimulating applications are in general highly injurious. 
As soon as the inflammation has been in some degree moderated, 
blisters should be laid on the temples, or immediately over the 
closed eye-lids, and kept discharging by some irritating ointment. 



OF OPHTHALMIA. 273 

When applied directly over the eyes, they generally produce a 
more speedv and decided redaction of the inflammation than when 
laid on the temples. Under the prompt and active employment 
of these antiphlogistic measures, the pain, irritation, and swelling, 
usually begin to subside about the third or fourth day, and the 
discharge becomes gieety, at the same time that the conjunctiva 
assumes,- a paler and. flabby appearance. When the inflamma- 
tion has thus, in part, subsided, recourse must be had to astringent 
and stimulating collyria. It is of great consequence, however, 
that remedies of this kind be not applied, until, the inflammation 
is considerably reduced. The mOst serious injury may result from 
exciting applications to the eye, during the active, stage of the dis- 
ease. After the discharge has acquired a gieety character, and 
the swelling and redness of the lids and conjunctiva are obviously 
moderated, great benefit may be derived from remedies of this 
character. A solution of the chloruret of litne, in the proportion 
of about ten grains to an ounce of distilled water, has been found 
peculiarly useful in the purulent ophthalmia of infants. I have 
myself employed it, in several cases, with unequivocal benefit. 
The nitrate of silver also, in the proportion of two grains to the 
ounce of water, forms an excellent local astringent in this affec- 
tion. A few drops of this solution should be introduced into the 
eye, two or three times in the course of twenty-four hours. The 
best way of doing this is to lay the infant on its back, and pour a 
small portion of the solution into the inner angle of the eye. By 
slightly separating the lids the fluid insinuates itself between them 
and comes in contact with the inflamed conjunctiva. I have fre- 
quently injected this solution under the eye-lids with a small 
syringe, and generally with manifest advantage. When used in this 
way it must be diluted with an equal quantity of warm water. Dr. 
Dewees prefers a solution of the sulphate of zinc in rose water (in 
the proportion of a grain of the former to an ounce of the latter) 
to all other astringents. I have occasionally employed this article 
and generally with evident benefit. Its good effects, however, are 
commonly much less prompt and decided, than those of the nitrate 
of silver or the chloruret of lime; and in several instances where 
its use was not attended with any obvious benefit, I have known 
the nitrate of silver injected in the way just mentioned, to produce 

2 N 



274 OF OPHTHALMIA. 

very excellent effects. This writer appears to me to entertain 
greater apprehensions of injurious consequences from the use of 
astringent collyria in this affection than is, I thinlq warranted by 
experience. During the active and unmitigated progress of the 
inflammation, all such applications to the diseased conjunctiva are 
unquestionably decidedly improper; but after the violence of the 
inflammation has been moderated, and the .purulent secretion be- 
comes profuse, thin and greenish, applications of this kind are not 
only harmless, but in general indispensable to the entire removal of 
the disease. I have never known any obvious injury to result from 
the use of nitrate of silver at an' advanced stage of the complaint; 
and I have, in some cases, employed a solution of the strength of 
four grains to the ounce of water. Travers and several other 
writers, recommend a solution of alum, of the strength of two. 
grains to an ounce of water. 

Should the inflammation, unfortunately, go on to ulceration and 
sloughing of the cornea, the infant's system ought to be supported 
by tonics and anodynes. A teaspoonful of a weak infusion of the 
cinchona bark should be given three or four times daily, with the 
addition of a drop of laudanum every evening. 

Scrophulous, or Exanthematous Ophthalmia. — This variety of 
ophthalmia generally occurs during childhood, and is frequently 
the first manifestation of the scrophulous diathesis. It is not, how- 
ever, always attended with a scrophulous habit; and it may even 
be doubted whether its connection with the strumous diathesis is 
sufficiently common, to justify the term" scrophulous," by which it 
is usually designated. From its frequent association with eruptive 
affections about the head, the term exanthematous, has been given 
to it by Mr. Wardrop;* and Mr. Christian of Liverpool, has de- 
scribed the same affection under the name of porriginous ophthal- 
mia, from its being in many instances preceded by porriginous 
pustules on the face and scalp.t Mr. Wardrop, however, affirms, 
that scrophulous inflammation of the eyes, " is a disease quite dis- 
tinct from exanthematous ophthalmia." 1 cannot undertake to 
decide upon this point; but I am very sure, that all the cases of 

* Transact. Med. Chir. Society of Edinburg, vol. ii. f Glasgow Med. Jour. No. I. 



OF OPHTHALMIA. 275 

ophthalmia which I have hitherto met with in children, and 
regarded as instances of scrophulous inflammation of the eyes, were 
characterized by the same phenomena that are ascribed to the 
exanthematous variety of the disease. 

This form o( ophthalmia is frequently attended with discharging 
sores behind the ears, and pustular eruptions on the scalp and face. 
The disease is characterized, by excessive intolerance of light, an 
enormous secretion of tears, and a muco-purulent secretion from 
the glands of the tarse, which, during sleep, is apt to agglutinate 
the eyelids. The pain, except in the commencement, is seldom 
great, and is attended with the peculiarity, that firm pressure upon 
the eye, always affords very considerable relief. Nor is the red- 
ness of the conjunctiva generally very conspicuous; but in recent 
and acute cases, an effusion of serum sometimes occurs around the 
cornea, giving rise to an elevated, cedematous circle, about a line 
or more in thickness, occupying the margin of the cornea, and 
presenting a peculiar reddish brown appearance (Jeffreys). Chil- 
dren, who arc afflicted with this disease, are so painfully affected 
by the light, that they are constantly resorting to every mode in 
their power, for excluding it, as much as possible, from their eyes. 
The little patient keeps his eyes continually closed, holding the 
head down, and pressing his hands or a handkerchief firmly upon 
the eyes ; or he rests his head against a chair in some obscure part of 
the room, or lies with the face buried in a pillow, or in the attendant's 
lap. "The intolerance of light is always most severe in the morning; 
and in the afternoon, it sometimes remits so much, as to allow the 
patient to open his eyes.'' The tears are not only extremely profuse, 
but so hot and acrid that they irritate and frequently excoriate the 
cheeks, alas of the nose and upper lip. The parts immediately 
under the eyes, are almost constantly inflamed, and covered with 
a minute pustular eruption. In the majority of cases, the eyelids 
become somewhat swollen with turgid veins ramifying on their 
surface. " On trying to open the lids, a torrent of tears gushes 
out;" and the patient keeps them so firmly closed, particularly 
when an effort is made to open them, that it is always extremely 
difficult to obtain a view of the eye. Neither the kindest lan- 
guage, "nor the severest punishment," will induce the little 
patient to open his eyes; and such, indeed, is the suffering which 



276 OF OPHTHALMIA. 

is occasioned by the light, that the utmost effort of the will seems 
incapable of overcoming the involuntary contraction of the orbic- 
ularis of the eyes. In many instances, minute vesicles appear 
scattered over the cornea and conjunctiva. These vesicles break 
in violent cases, and form superficial ulcers. If the inflammation 
be not checked, these ulcerations sometimes gradually penetrate 
deeper into the substance of the cornea, until they form an open- 
ing into the anterior chamber and give exit to the aqueous hu- 
mor. This unfortunate termination, however, occurs but very 
seldom, and only in cases of a very acute and violent character. 
More or less opacity of the cornea, is a very common occurrence; 
and when the disease becomes chronic, this event is inevitable. 
In cases of long continuance, tinea ciliaris and lippitudo occur; 
minute pustular ulcerations appear along the roots of the eye- 
lashes, exuding a muco-purulent fluid, by which the edges of the 
eyelids are glued together; or the margin of the lids acquire a red 
and excoriated condition. 

In general the pustular eruption about the head, and the dis- 
charging sores behind the ears, which precede the occurrence of 
this variety of ophthalmia, disappear soon after the inflammation 
of the eyes is fully developed. If these eruptions recur during 
the progress of the disease, then the inflammation of the eyes 
generally subsides, and the cornea can be examined. Wardrop 
asserts, that in exanthematous ophthalmia, no morbid secretion 
from the meibomian glands ever takes place. This statement is, 
however, contradicted by other writers ; and I am confident, that 
I have seen several cases, unequivocally of this kind, in which 
there was manifest disease in the edges of the lids, attended with 
a glutinous secretion from these minute glands. 

Along with these local symptoms, there are always distinct 
manifestations of constitutional disturbance. The child is gene- 
rally fretful and irritable; the pulse frequent, quick and sharp; 
the skin often preternaturally warm and dry; the tongue covered 
with a thin white fur, and the stomach and bowels in a disordered 
condition. In many cases the abdomen is tumid and hard, the 
breath very offensive, and the alvine evacuations irregular and 
of an unnatural appearance. In cases of long standing, the 



OF OPHTHALMIA. 277 

flesh wastes, — particularly on the extremities, and the system 
becomes feeble and very irritable. 

This form of ophthalmia is most frequently met with among 
the poor, of relaxed and irritable habits, " who have a white 
pasty complexion, with a tense and swollen state of the abdomen, 
and not unfrequently, enlarged lymphatic glands." It frequently 
succeeds measles, scarlet fever and other exanthematous diseases; 
more especially when soon after the subsidence of these affections, 
the individual has been subjected to the morbific influence of a 
cold and damp atmosphere. Children who have suffered eruptive 
affections about the head from difficult dentition, and who are 
much pampered with improper articles of food, often become 
affected with this variety of ophthalmia — more especially when 
the eruptions or discharging sores, have been prematurely dried 
up, by astringent and stimulating applications. It is probable, 
that this irritable form of ophthalmia is often excited by the 
ordinary causes of conjunctival inflammation, such as cold, dust 
or other common sources of irritation, and that it assumes the 
aggravated and obstinate character peculiar to this complaint, in 
consequence of a highly irritable and depraved habit of the 
system, from the influence of previous diseases or morbific causes. 

Treatment. — In the commencement of the treatment of this 
variety of inflammation of the eyes, the principal attention, is to 
be directed to the general state of the system. All local appli- 
cations of a stimulating or astringent character are not only 
wholly useless, but decidedly improper, until the morbid condi- 
tion of the system has been improved, by a judicious course of 
general treatment. 

General bloodletting does not appear to exert any obvious 
influence in subduing scrophulous or exanthematous ophthalmia. 
In recent and very acute cases, however, some advantage may 
occasionally be derived, from the application of leeches to the 
temples and external angles of the eyes: but in instances of chro- 
nic character or of long continuance, leeching is not only wholly 
useless, but often decidedly injurious in its consequences. In the 
beginning of the treatment, the bowels ought to be thoroughly 
evacuated, and afterwards kept in a loose state by the regular 



278 OF OPHTHALMIA. 

administration of suitable laxatives. Free and repeated purging 
is particularly important, when the abdomen is tumid and hard, 
and the alvine discharges of an unnatural character. " Even 
when this ophthalmia appears in a feeble and emaciated child, 
it will, usually be found, that, by the exhibition of purgatives, 
feculent matter, both unnatural in quantity and in quality, will 
be evacuated; and until its evacuation has been completely 
effected, other remedies will avail but little." Calomel com- 
bined with rhubarb, or jalap, should be given every two or three 
days, in doses sufficiently active, to produce pretty copious purg- 
ing; or a few grains of colomel may be administered late in the 
evening, and followed, next morning by a dose of castor oil, er 
senna infusion. In cases that have assumed a strictly chronic char- 
acter, repeated active purging is not, in general, beneficial. 
After the bowels have in the first place, been well evacuated, it 
will be sufficient, in instances of this kind, to keep them mode- 
rately loose, by small doses of calomel and castor oil. In all 
instances indeed, particular attention should be paid to the alvine 
discharges, and in proportion as they are observed to acquire a 
more natural appearance, the purgatives must be given at longer 
intervals and in less efficient doses; "for though the greatest 
benefit will be obtained, by evacuating the bowels, long con- 
tinued and violent purging will be found equally prejudicial." 

In some cases the digestive organs are prominently deranged — 
the appetite being variable and capricious, sometimes much 
depressed, and at others quite voracious. When this is the case, 
emetics are capable of procuring very considerable advantage. 
An aqueous solution of tartar emetic, appears to be the best 
article for this purpose. The emetic may be repeated every 
third or fourth day during the active stage of the inflammation. 
In protracted or chronic cases they rarely prove beneficial. 

To promote the regular performance of the various excretory 
functions, minute portions of calomel and pulvis antimonialis 
should be given, several times daily; and when the system is 
very irritable, and the child does not rest well at night, a few 
grains of Dover's powder may be very advantageously added.* 

* R- Calomel grs. ii. Pulv. Antimonialis Doveri— -aa vi. Divide into equal 

parts. Give one every six hours. 



OF OPHTHALMIA. 379 

After the disordered condition of the alimentary canal has been 
improved, by the means just mentioned, much benefit may some- 
times be derived, "from the carbonates of soda and potass, either 
singly or combined with rhubarb and the bitter infusions."* The 
sulphate of quinine, also is a highly valuable remedy in this 
variety of ophthalmia, after the bowels have been properly 
evacuated. Dr. Mackenzie of Glasgow, asserts, that he has used 
it in a great many cases, and that, in the majority of instances 
its beneficial effects, " were very remarkable." In most of the 
little patients to whom the quinine was administered, "it acted 
like a charm." Sir A. Cooper, too, speaks in the most favorable 
terms, of the employment of this article in scrophulous inflamma- 
tion of the eyes. I ha«ve myself, used it in nine or ten cases of 
this obstinate complaint, and in every instance with unequivocal 
benefit. In three of these cases, it effected a speedy and com- 
plete removal of the inflammation and morbid sensibility of the 
eyes. It is proper to observe, however, that its good effects can 
seldom be obtained at a very early period of the disease, and 
before the disordered condition of the bowels has been improved 
by mercurial purgatives, and a mild and digestable diet. The 
dose for a child of from three to seven years old, should be from 
a quarter to half a grain three times daily. 

Various other internal remedies have been recommended for 
the cure of this malady — amongst which the muriate of barytes, 
and the iodine, appear to be the most important. Hufeland, in a 
small work on the employment of the former of these articles in 
scrophula, gives an account of five or six instances of scrophulous 
inflammation of the eyes, which yielded to the. influence of this 
remedy. I have prescribed it, in several cases of this complaint, 
with considerable advantage, and it appears to me, worthy of 
more attention, in this respect, than it has, of late years received. 
The best mode of exhibiting this article is in solution. A half 
a drachm of the muriate of barytes, should be dissolved in an 
ounce of distilled water; of this solution, from ten to twenty 
drops may be given, to a child between two and seven years of 
age. The best vehicle for administering it, is sarsaparella syrup, 

* Wardrop. loc. citat. 



280 OF OPHTHALMIA. 

or the compound decoction of this root, as directed in the Dis- 
pensatories. The iodine has, of late, been strongly recommended 
as a remedy in this form of ophthalmia; but my own experience 
has not furnished me with any evidence of its usefulness in this 
respect. I have prescribed it in four cases of this kind, and al- 
though its use was continued for several months, not the slightest 
benefit resulted from it, in any instance. Nevertheless, no incon- 
siderable number of cases have been reported, in which this arti- 
cle is said, to have proved decidedly beneficial, and from its well 
known influence over strumous affections it is, doubtless entitled 
to attention as a remedy in the present disease. 

Astringent and stimulating applications to the eyes seldom 
afford any permanent relief; and when usjed at an early period, be- 
fore the general health has been improved, they may do mischief. 
As palliatives, however, slightly astringent collyria, such as a 
weak solution of the sulphate of copper, or of nitrate' of silver, 
may sometimes be used with advantage. When the inflamma- 
tion and pain are considerable, much relief is usually procured by 
fomenting the eyes, four or five times daily, with a decoction of 
white poppy heads, with a small portion of the extract of conium 
dissolved in it. I have repeatedly employed the nitrate of silver 
for this purpose, and occasionally with evident advantage. A 
few drops of a solution, of the strength of two grains to an ounce 
of water are to be instilled into the eye, once or twice daily. 
Mr. Mackenzie speaks favorably of a collyrium, composed of one 
grain of the muriate of mercury to eight ounces of water. After 
the intolerance of light and excessive secretion of tears has been 
so far subdued, as to enable the patient to open his eyes in a 
moderate light, considerable benefit will often result from the in- 
troduction of a small piece of red precipitate ointment (15 grains to 
an ounce of lard) within the eye-lids. At this stage of the disease 
important relief may often be obtained from slightly scarifying the 
conjunctiva of the lids. "If," says Mr. Wardrop, "a superficial 
incision, or rather a very slight scratch be made, with a sharp- 
edged instrument, or a common wedge-shaped scarificator, across 
the enlarged and distended vessels of the palpebral conjunctiva, 
the under eye-lid being previously completely everted and pressed 
on the edge of the orbit, an astonishing quantity of blood will 



OF OPHTHALMIA. 281 

sometimes flow, and the relief obtained from this simple operation 
is often very remarkable. If this operation is followed by con- 
siderable alleviation, it may be a few times repeated, until the in- 
creased fulness of the vessels and thickening of the eye-lids are 
removed, and one or two days allowed between each operation. 
Sometimes, however, the mere abstraction of blood is not suffi- 
cient to produce such a beneficial result, and then a small piece 
of the common ointment of the red oxide of mercury, may be put 
within the eyelids, immediately after the blood has been drawn." 

When the tarsi are much affected, benefit may be obtained 
from the application of the red-precipitate ointment, of the 
strength mentioned above, to the edges of the lids. The citrin 
ointment, will also be found of great use, in such cases. When the 
disease is so far subdued as to admit of an examination of the 
cornea, "one or more specks, will generally be discovered, and 
in many instances distinct ulceration." If small pustules be ob- 
served on the cornea, they should not be opened by art, as they 
are then apt to degenerate into corroding ulcers, an occurrence 
which always greatly increases the obstinacy of the disease as 
well as the risk of ultimate loss of sight, from destruction or per- 
manent opacity of the cornea. 

Blisters do not often procure any obvious benefit in scrophulous 
ophthalmia. In cases manifestly attended with a scrophulous habit 
they may even do harm, by the pustular inflammation which is apt 
to occur around the blistered part, and the consequent additional 
source of general and local irritation which is thus produced. When 
however, the disease succeeds the healing or drying up of discharg- 
ing sores behind the ears, or scabby eruptions about the head, con- 
siderable benefit may be obtained from a succession of small blis- 
ters behind the ears. In general, however, the insertion of a 
seton in the back of the neck, is much more efficacious than vesi- 
cation in this variety of ophthalmia. After the acute character 
of the disease has subsided, the establishment of such a drain will 

almost always produce favorable effects. To prevent a relapse 

and the tendency to a return of the disease is usually very great 
— the seton or pea issue is peculiarly valuable. 

During the whole course of the treatment particular attention 
must be paid to the diet and habits of life. In recent and acute 

2 O 



282 OF OPHTHALMIA. 

cases of the nourishment should be simple and unirritating, such 
as liquid and farinaceous preparations or thin animal broths; but 
in instances of a strictly chronic character, particularly when 
attended with feebleness and relaxation a more nourishing though 
plain and digestable diet must be allowed, in order to support the 
vigor of the system. All stimulating drinks, such as wine, and 
malt liquors must be carefully avoided. " The body should not 
be loaded with cloths, and the head particularly ought to be but 
slightly covered: protecting the eyes with only a single and nar- 
row fold of black silk, hanging loosely over them, and not wearing 
a large bonnet. The hair ought to be cut very short, and the 
greatest advantage will be found from sponging the head and neck 
with fresh water every morning — using it at first of an agreeable 
temperature, and making it colder by degrees, particular care be- 
ing taken to dry the head well afterwards" (Wardrop). During 
the declension of the disease, and after it has been subdued, regular 
exercise in the fresh and salubrious air of the country, sea-bath- 
ing, and the tepid shower bath, will contribute very materially to 
the entire and permanent removal of the complaint. 



OF CHOLERA INFANTUM. 283 



CHAPTER XXIII. 



OF CHOLERA INFANTUM. 



The cholera of infants diners in several material points, from the 
ordinary cholera of adults. It is almost invariably attended with 
distinct febrile irritation — frequently comes on in a gradual man- 
ner — and is peculiarly liable to become protracted in its dura- 
tion or to assume a chronic character. In many instances the 
disease commences with diarrhoea, which after having continued 
for a few days becomes associated with more or less violent vom- 
iting. In the majority of cases however, the vomiting and pur- 
ging come on nearly at the same time, without any other 
premonitory symptoms, than, perhaps, diminished or unusually 
craving appetite, flatulency and acidity of the prima? viae, 
langour, and an uneasy and fretful temper. From the com- 
mencement of the disease, whether its accession be sudden or 
gradual, the pulse is usually frequent, quick, small and somewhat 
tense. The tongue is generally, at first, covered with a thin 
white fur; but in the progress of the disease,— particularly 
when it tends to a chronic form, its surface often acquires a 
dry, red, smooth or polished appearance. At first the discharges 
from the bowels usually consist of a turbid frothy fluid, mixed 
with small portions of green bile, or of a nearly colorless water 
containing small flocculi of mucus. After the disease is fully 
developed, the evacuations very rarely exhibit any traces of 
bilious matter, the biliary secretion being evidently entirely sus- 
pended. In some instances the disease commences and proceeds 
with such violence, as to exhaust the vital powers and termi- 
nate in death in the coun|fe>f a single day. More commonly 
however, the vomiting aiSBrging are not so rapid as to pros- 
trate the system immediate^ and the disease continues for five 



284 OF CHOLERA INFANTUM. 

or six days, before convalesence begins or fatal exhaustion 
ensues. In many instances the vomiting, in the course of four 
or five hours, becomes less and less frequent, and finally ceases 
altogether, or recurs only two or three times daily, while the 
diarrhoea goes on, until, at last it assumes a strictly chronic cha- 
racter. In the early stages of the disease, the little patient is 
evidently harassed with painful and distressing sensations in the 
stomach and bowels; and when the discharges are violent and 
very frequent, the muscles of the abdomen, and even those of the 
extremities are apt to become affected with spasmodic contrac- 
tions. If the disease does not terminate fatally, during the first 
few days, rapid emaciation ensues; the hands and feet become 
cold and pale, while the head and body are always preternaturally 
warm;\the skin is usually dry and harsh and acquires a peculiar 
wilted appearance, particularly on the inner part of the thighs, 
and over the abdomen. The countenance becomes pale and 
contracted, the eyes, inanimate, and sunk, the nose sharp, and 
the lips thin, dry, and shrivelled. The thirst is always very great, 
more especially after the disease has continued for some days, and, 
no drink is palatable but cold water, which is generally thrown 
up soon after it is swallowed. Food of every kind is usually 
loathed and refused. If the disease be not subdued or moderated, 
by proper remedial means, the little patient, by degrees 
becomes somnolent,he sleeps with the eyes half open, rolls his head 
about, when awake, and at last, sinks into a state of insensibility 
and coma, and dies in a paroxysm of convulsions, or under symp- 
toms resembling those of the last stage of acute hydrocephalus. 
When the disease is of protracted duration, or assumes a chro- 
nic form, the alvine discharges generally acquire a dark, very 
offensive, and acrid character. The digestive powers become 
so enfeebled, that almost " every thing taken into the stomach 
passes through the bowels, in an imperfectly digested state." 
Aphthae finally appear on the tongue and inside of the cheeks; 
the face acquires a bloated or oedematous appearance, the abdo- 
men becomes tumid and tympanitic; the parts about the anus 
are excoriated by the acrid dischaj^, and towards the fatal con- 
clusion, spots of effused blood undflBc cuticle, sometimes appear 
on various parts of the body — rmfe especially on those upon 



OF CHOLERA INFANTUM. 285 

which the patient lies. The little patient at last lies in a coma- 
tose and insensible state, with the eye lids half open, and the globe 
of the eye turned up so as completely to hide the cornea. Dr. 
Dewees states that in many instances as death approaches, " a 
crystalline eruption" appears on the chest, consisting of an 
immensity of watery vesicles of a very minute size, which he 
says, " as far as he has observed," are always indicative of a fatal 
termination. "This symptom, he says, may readily escape ob- 
servation if not looked for; it requires that the surface on which it 
has spread itself, should be placed between the eye and the light, 
and viewed nearly horizontally." I have, myself, never witnessed 
this eruption, but I do not doubt the correctness of the Doctor's 
observations on this point. There is another symptom mentioned 
by this respectable writer, which I have sometimes noticed in 
the last stage of this complaint, and which I have also occasion- 
ally observed in other forms of chronic disease of the alimentary 
canal; it is" the thrusting the fingers, nay almost the whole hand 
into the backpart of the mouth, as if desirous of removing some- 
thing from the throat." This symptom is no less unfavorable 
than the preceding one. 

The duration of cholera infantum is exceedingly various. It 
sometimes runs on to a fatal termination in the course of five or 
six hours. In other cases, the disease continues for many weeks, 
until the body is reduced to a state of extreme exhaustion and 
emaciation, and, nevertheless terminates favorably. Death some- 
times takes place " most unexpectedly;" and recoveries, now and 
then occur "in a state of things apparently hopeless." When 
bilious matter begins to make its appearance in the evacuations 
and becomes more and more copious, a favorable result may be 
expected; but when the discharges become watery and nearly 
colorless, and continue in this state, a fatal termination is inevi- 
table. I have never yet witnessed an instance of recovery 
from this malady, without the appearance of more or less bile in 
the alvine evacuations. So long as the liver remains torpid, the 
morbid irritability and inordinate action of the bowels will con- 
tinue. A uniform moisture accompanied by a natural tempera- 
ture of the skin, is a highly favorable symptom; for such is the 
sympathetic connection subsisting between the liver and the 



286 OF CHOLERA INFANTUM. 

skin, that the latter scarcely ever resumes its regular functions 
without a simultaneous recurrence of the biliary secretion. When 
the pulse becomes feeble and thready, the discharges from the 
bowels watery and colorless — or reddish like the washings of 
flesh, or turbid foetid and mixed with flocculi of mucus, accompa- 
nied with great uneasiness, and jactitation, or stupor and partial 
insensibility; and when in addition to these symptoms the skin 
becomes cold and clammy, and the countenance pale and cadave- 
rous the worst consequences are to be apprehended. 

When death takes place early in violent and rapid cases, the 
vessels of the liver, stomach, and intestines, are found, on dis- 
section, engorged with blood. The mucous membrane of the 
bowels, generally exhibits traces of inflammation; and when the 
disease has continued for a considerable length of time, ulcera- 
tion and abrasion of this structure, are occasionally met with. In 
some instances, considerable portions of the intestinal tube are so 
much contracted as scarcely to admit a small sized quill. The 
liver, besides the engorged state of its bloodvessels, is often 
greatly enlarged, particularly in cases of long continuance, and 
this enlargement is usually attended with a manifest increase of 
the firmness and denseness of its structure. In the majority of 
cases the gall bladder contains a pale or almost colorless fluid; 
but in some instances it is filled with a dark green and viscid 
bile. The brain in nearly all cases, is in a highly congested 
condition; and in protracted cases, serous effusions into the ven- 
tricles and upon the surface, of this organ are frequently met 
with. 

The etiology of the cholera of infants, differs in some important 
circumstances, from that of the ordinary form of the disease in adults. 
Both these varieties of cholera, are almost exclusively confined 
to the hot months of the year; but cholera infantum is vastly 
more prevalent in large and crowded cities than in the coun- 
try — a circumstance which does not obtain, in relation to the 
cholera morbus of adults. During a practice of twelve years in 
the country, I met with but two or three cases of this disease in 
infants. Again, the cholera of infants very rarely occurs pre- 
vious to the third month, or after the twenty fourth month of 
age, — its occurrence being almost exclusively confined to the 



OF CHOLERA INFANTUM. 287 

period during which the process of primary dentition is going 
on. There are therefore three causes whose concomitant influ- 
ence is intimately concerned in the production of this variety of 
cholera; namely, high atmospheric temperature, the contami- 
nated air of crowded cities, and the irritation produced by 
dentition. From the great prevalence of this disease during 
the hot months of summer, in the more filthy parts of crowded 
cities, it has been supposed, that it is a malarious malady, and 
"a mere variety of the bilious fever of our climate, the force of 
which is turned inwards upon the intestines"*. In support of 
this opinion, it is alleged by the respectable physician just quoted, 
that though seldom met with in salubrious districts of the country, 
"a majority of the children fall victims to cholera infantum, in the 
neighborhood of marshes, or in low, wet and otherwise unhealthy 
situations." This however is, by no means, confirmed by the ob- 
servations of those who practice in paludal districts, where 
miasmata are most abundant. Unquestionably, cholera is more 
common, both in infants and in adults, in miasmatic localities, 
than in the high and dry districts of the country; and there can 
be no doubt, that miasmata have a tendency to favor the occur- 
rence of this disease in infants as well as adults. That malaria, 
however, is not the principal morbific agent concerned in the 
production of cholera infantum, is evident from the circum- 
stance, that the disease is almost exclusively confined to the first 
two years of infancy. If this were the chief exciting cause of 
the malady, it could not be thus limited in the period of its oc- 
currence. It is, moreover, to be observed that this disease usu- 
ally commences as early as the latter end of May and acquires 
its most extensive sway in July, some time before the ordinary 
miasmatic diseases are wont to make their appearance in our 
climate, except here and there perhaps a few instances. In the 
eastern cities of this country, particularly in Philadelphia cholera 
infantum often prevails extensively during the months of June 
and July, when scarcely any of the diseases justly ascribed to 
the influence of miasmata are met with. 



* Dr. Condie. See his valuable Essay on " Cholera Infantum." — in the Phil'a 
Jour, of Med. and Phys. Sciences. May. 1825— p. 13. 



288 OF CHOLERA INFANTUM. 

High atmospheric temperature is manifestly, intimately con- 
cerned in the production of this dangerous complaint. It com- 
mences with the hot weather, "increases and becomes more fatal 
with the rise of the thermometer, and declines with the cool wea- 
ther in autumn. During its continuance, it may be observed to 
vary with every permanent change of temperature. A few very 
hot days in succession in the month of June, are sufficient to call 
it into action; and during the height of its prevalence, a spell of 
cold weather will diminish, if not suppress it."* But as high and 
continued heat seldom gives rise to cholera, in infants enjoying 
the pure air of the country, there must be some other circum- 
stance peculiar to cities which especially favors its tendency to 
develop the disease. This accessary cause consists, doubtless, 
in the confined and impure air of cities; and hence we aJways 
find this complaint most prevalent in the more crowded and filthy 
districts, and in the narrow and confined alleys, courts and avenues. 
" Let any one," says Dr. Parrish, " take a walk in a summer 
morning, through the thickly built lanes and alleys of Philadel- 
phia, he will be struck wtth the appearance of the children, 
reclining their heads, as if exhausted, upon the breast of their 
mothers, with a pale and languid countenance, a cool and clammy 
skin, a shrunk neck, and other signs of debility, arising from their 
confinement, during the night, to close and hot apartments." 

Dentition, also, manifestly contributes, in no small degree, to 
the occurrence of cholera infantum. Children, who have passed 
the period of primary dentition, though equally exposed to the 
heated and impure atmosphere, very rarely become affected with 
this complaint. It is evident, therefore, that the excitii g causes 
of the disease must be materially influenced by some cin umstance 
peculiar to infancy. It seems to me highly probable, that, in 
that irritable and enfeebled habit of body, which arises from the 
continued influence of a heated and impure air, the irritation of 
dentition is frequently intimately concerned in the production of 
this malady. In many instances the brain is in an irritated con- 
dition, even before the disorder of the stomach and bowels com- 



* Dr. I. Parrish. Remarks on the Prophylactic Treatment of Cholera Infantum, &c. 
North American Med. Jour. vol. ii. p. 68. 



OF CHOLERA INFANTUM. 289 

mences. Throughout the whole course of the disease, the head 
is always preternaturally warm, and in most cases, the infant is 
unusually restless, and fretful, for several days previous to the 
accession of the disease. The tendency of cerebral irritation to 
give rise to inordinate irritability of the stomach and bowels is 
well known. Diarrhoea is a very common, and when moderate, 
a salutary occurrence during the process of painful dentition. In 
the commencement of hydrocephalus, much gastric irritability and 
vomiting are seldom absent. In concussion of the brain vomiting 
is often a very troublesome symptom; and sea-sickness, which is 
often so violent as to resemble cholera, appears to depend entirely 
on a peculiar cerebral excitement occasioned by the swinging 
and rocking motion of a vessel at sea. The great tendency of 
cholera infantum, in its chronic form, to terminate in a state of 
cerebral oppression and coma, seems also to show, that the brain 
is especially predisposed to disease. 

We may, therefore, presume, that in the irritable condition of 
the system, produced by the influence of a very warm and con- 
taminated atmosphere, dentition causes more or less cerebral irri- 
tation, which being reflected on the stomach and bowels, renders 
them preternaturally irritable. If in this state of the alimentary 
canal, the cutaneous exhalents are over excited and debilitated 
by high atmospheric temperature, the slightest reduction of 
temperature, a current of fresh air, or damp night air, will readily 
cause a sudden torpor of these emunctories. The blood will 
retreat from the surface to the internal organs, and give rise to 
engorgement of the vessels of the liver and mucous membrane of 
the bowels, in consequence of which the irritability of the alimen- 
tary canal will be still further increased, and the characteristic 
symptoms of the disease excited. 

There is still another circumstance which must be taken into 

view, in an account of the exciting causes of cholera infantum 

namely, improper nourishment or errors in diet. Irritating, and 
inappropriate articles of food, are at all times apt to produce 
disorders of the stomach and bowels, and when the system is 
predisposed to affections of this kind, by the causes mentioned 
above, slight errors, in this respect, may give rise to an attack of 
cholera. A sudden transition from the bland and congenial 

'2 P 



290 OF CHOLERA INFANTUM. 

nourishment obtained at the mother's breast, to an exclusive 
artificial diet during hot weather, is often speedily followed by 
an attack of this dangerous malady. 

Treatment. — From what is stated above, in relation to the pa* 
thology of this affection, it would appear, that torpor of the 
hepatic and cutaneous functions, in connexion with cerebral 
irritation from dentition, exert a powerful influence, in develop- 
ing and sustaining that irritable condition of the alimentary 
canal, upon which the characteristic phenomena of the disease 
depend. No means calculated to allay the excessive action of 
the stomach and bowels, can be of any .permanent avail, if they 
do not, at the same time, tend to correct the morbid condition of 
the liver and skin; and hence, opiates and astringents are, not 
only useless, but almost invariably detrimental, unless accompa- 
nied by remedies capable of exciting these functions, and obviat- 
ing cerebral irritation. In prescribing for this disease, our prin- 
cipal objects, therefore, must be, to restore the regular action of 
the liver and skin, to obviate irritation and sanguineous congestion 
in the brain, and to determine the circulation from the engorged 
vessels of the liver and mucous membrane of the alimentary 
canal, to the external parts of the body. To answer these pur- 
poses, I generally commence the treatment, with the application 
of leeches to the temples or small blisters behind the ears, the 
exhibition of small doses of calomel and ipecacuanna, and a 
large stimulating poultice over the abdomen. I am persuaded, 
by what I have repeatedly witnessed in my practice, that great 
benefit will in general result from local depletion, or from the 
application of blisters behind the ears, or on the back of the neck, 
in this affection. During the last seven years, I have treated but 
very few cases in which I did not, at once, apply blisters behind 
the ears; and 1 may confidently affirm, that since I have 
adopted this practice, I have been much more successful in the 
management of this disease, than previously. Dr. Parrish was, 
I believe, the first who pointed out the usefulness of blisters 
about the head in the cholera of infants. " In severe cases," he 
says "much good may be expected from the application of blisters 
behind the ears. I was led to this practice, by observing that 



OF CHOLERA INFANTUM. 291 

the eruption, which, during dentition, is apt to make its appear- 
ance behind the ears, often proves a most salutary effort of 
nature; and that while it continues, the infant generally enjoys 
an exemption from those dangerous disorders incident to this 
critical period of life. To imitate nature as closely as possible, 
the discharge from the blistered surface should be maintained for 
some time, by stimulating dressings. I have witnessed the most 
beneficial effects from this practice and can strongly recommend it 
to the attention of the profession."* The gums should always 
be carefully examined in cases of this complaint. If they are in 
a swollen or inflamed and painful state, they should be freely 
divided, down to the advancing teeth. For the purpose of mode- 
rating the gastro-intestinal irritability and of stimulating the 
action of the liver, minute portions of calomel and ipecacuanna 
constitute, I think, the most efficient internal remedy we possess. 
From one sixth to a quarter of a grain of calomel in union with 
a quarter of a grain of ipecacuanna should be given every half 
hour, or hour, until the evacuations become mixed with bilious 
matter. The appearance of bile in the evacuations, is always to 
be hailed, as a very favorable sign; and the sooner the liver can 
be brought to resume its secretory action, the greater, in general 
will be the probability of ultimate success in our attempts to 
subdue the disease. Indeed so long as the liver remains inactive 
and the alvine discharges free from bile, the disease may be 
regarded as still possessing all its violence and dangerous ten- 
dency, whatever temporary abatement may occur in the severity 
of the vomiting and purging. Ipecacuanna, in minute doses is a 
most excellent auxiliary to the calomel, in affections attended 
with morbid irritability and excessive peristaltic action of the 
alimentary canal. Its tendency to counteract inordinate action 
of the bowels, when given in very small portions is very consider- 
able, and its tendency, moreover, to excite diaphoresis, renders 
it still more applicable in this and other intestinal affections of 
this kind. When the vomiting and purging are extremely fre- 
quent, other means calculated to calm the irritability of the sto- 
mach and bowels may be advantageously used along with the 

* loco citat. 



292 OK CHOLERA INFANTUM. 

calomel and ipecacuanna. The spirits of turpentine is an excel- 
lent remedy for this purpose. Dr. Condie, states that in his 
practice, the administration of from ten to thirty drops of this 
remedy, three or four times daily, "has not in a single instance 
failed in speedily checking the disordered action of the stomach." 
I have used this article in a considerable number of cases, and in 
most instances, with decided benefit. I prefer, however, giving 
it in much smaller and more frequent doses — namely, from four to 
six drops every hour until the violence of the vomiting has been 
moderated. I have also, occasionally, used a solution of camphor 
in sulphuric ether, (a drachm of the former to an ounce of the 
latter) with very obvious advantage.. Five or six drops of -this 
solution given every half hour or hour, seldom fails to moderate the 
excessive vomiting in this complaint. A large stimulating poul- 
tice, applied over the abdomen, is, generally, of material service 
in allaying the inordinate action of the stomach and intestines. 
Two or three tablespoonfuls of powdered black pepper, with a 
few teaspoonsful of cayenne, mixed up with a common emolient 
poultice will answer very well for this purpose. The application 
of a piece of flannel moistened with a mixture of equal parts of 
spirits of camphor and tincture of capsicum, often produces a 
very good effect. Blistering, however, is, I think decidedly 
the most efficient counter-irritating application. Before the 
blister is applied to the epigastrium, the part should be slightly 
bathed with spirits of turpentine, in order, to procure vesication 
as speedily as possible. The vesicatory should not be suffered to 
remain on the skin more than four hours. As soon as the surface 
is uniformly inflamed, which in children usually occurs in about 
four hours, and sometimes much sooner, the plaster ought to be 
removed, and a thick, and soft emolient poultice laid over the 
whole abdomen, including of course the inflamed surface. The 
poultice will, in a short time, excite the inflamed vessels to pour 
out a copious quantity of serum, under the cuticle, and raise a 
large blister, which should then be opened, and dressed with 
mercurial ointment prepared without turpentine or other irrita- 
ting substances. 

When from the tumid and tense state of the abdomen, there is 
reason to presume that the bowels are loaded with fseca] matter, 



OF CHOLERA INFANTUM. , 293 

the first few doses of calomel should be sufficiently large to pro- 
cure its purgative operation. A grain or two may be given every 
two or three hours, .until its evacuant effects are decidedly pro- 
cured. After the faeculent. contents of the bowels have been well 
evacuated, in this way, it will, I think, in general, be best to 
return to the minute and frequent doses of this article mentioned 
above. Except under the circumstances just mentioned — namely, 
a loaded state of 'the bowels, purgatives are not, in general, ad- 
visable in the commencement of the disease. When the disease 
continues, however, until the liver, under the .exciting influence 
of the calomel, pours out an abundance of bile, mild laxatives are 
undoubtedly very useful. In cases that come on gradually and 
proceed slowly, it may perhaps be better to commence at once 
with purgative doses of calomel, than with the minute portions 
mentioned above. In instances of this kind, the bowels are fre- 
quently much loaded with fcecal matter and vitiated secretions, 
which it is of much consequence to evacuate, as speedily and 
completely as can be done, without resorting to very active or 
irritating purgatives. When there is reason to suspect the. exist- 
ence of acid in the stomach and intestines, much benefit may be 
derived from the administration of five or six grains of prepared 
chalk, with each dose of calomel and ipecacuanna;or what is, 
perhaps, preferable, from the use of small portions of magnesia in 
combination with ammonia, as recommended by Dr. Kuhn.* I 
have in some instances of this kind, administered six or eight 
grains of calcined magnesia, in union with five or six drops of the 
abovementioned etherial solution of camphor, with the happiest 
effect. Indeed,, this combination' is not only peculiarly effectual 
in cases attended with acidity in the primae vise, but is also a 
highly valuable remedy, for allaying gastric irritability, or exces- 
sive vomiting, even where there is a total freedom from acid. 

When the abdomen is tumid, tense and tender to the touch, 
whilst the pulse is frequent, contracted and quick, blood ought to 

* " The prescription made use of by Dr. Kuhn," says Dr. Condie, "was the following :' 
R Magnes. calcinat. 9'iv; pul. g. arab.. 9i: sacch. alb. 3ii; aq. menth. pep.gss; aq. 
fontanae 3»ss; M. : add aq. ammonia pura, gtt. xlviii to clxiv, according to the age of 
the patient. The dose of this mixture is a teaspoonful every two hours. Vide Dr. Con- 
die's Essay. Loct. Cital. ' 



294 OF CHOLERA INFANTUM. 

be abstracted either with the lancet, or by the application of 
leeches to the epigastrium. If blood be not promptly and effi- 
ciently abstracted, in cases attended with these symptoms, it will 
be " in vain to depend upon the effects of any remedy; for inflam- 
mation and its consequences will have ensued, long before we 
can hope to make any impressions on the affected viscera, even 
by the use of calomel." After blood has been abstracted, in cases 
of this kind, a blister ought to be applied ovet the upper portion 
of the abdomen. In all instances indeed, whether attended with 
symptoms of abdominal inflammation or not, blistering the region 
of the stomach, is a most useful mode of making counter irritation. 

The warm bath, also, is an excellent auxiliary in the treatment 
of this disease. It is especially indicated, when the skin is very 
dry and harsh, and the pulse quick and irritated. While the pa- 
tient is immersed in the warm water up to the neck, a napkin wet 
with cold water, should be applied to the head, in order to lessen 
the determination of blood to the brain. 

In the early stage of cholera infantum, the use of opium is, in 
general, highly improper. The great tendency to congestion and 
irritation of the brain, in this affection, renders all medicines of 
this kind decidedly prejudicial when given at an early period of 
the disease, or where, in its advanced stage, symptoms of cerebral 
oppression are manifestly present. Nevertheless, when in the 
chronic form of the disease, the patient is very restless and wake- 
ful, with a dry and withered state of the skin, and there are no 
particular indications of cerebral congestion, small doses of Do- 
ver's powder, in union with minute portions of calomel, will some- 
times produce very excellent effects. Great caution, however, 
ought to be used, in the administration of opium, even in cases 
of a strictly chronic character. I have witnessed some instances 
of this kind, in which the employment of this narcotic was spee- 
dily followed by stupor or cerebral compression without any ob- 
vious beneficial effect on the intestinal disorder. 

Astringent and absorbent remedies are in general decidedly 
improper, in the early stage of the complaint. Much mischief 
has been done by the early administration of cretacious juleps, 
astringent mixtures, aromatic draughts and opiates in this malady. 
After the faeculent contents of the bowels have been well evacu- 



OF CHOLERA INFANTUM. 295 

ated, and .the secretory action of the liver has been excited by 
calomel, and in cases that have assumed a chronic character, the 
milder or less stimulating astringents, will, under judicious man- 
agement, often procure very considerable benefit. I have, in 
some instances, derived very obvious advantage from a decoction 
of the root of the geranium maculatum in milk, in the advanced 
stages of the complaint. The acetate- of lead has been very favor~ 
bly mentioned, as a remedy in this affection. As early as 1805 
Dr. Mann of Massachusetts, recommended this article, as capa- 
ble of procuring "considerable benefit in this disease."* Dr. Irwin 
of Charleston, South Carolina, also speaks strongly in favor of the 
employment of this remedy in the cholera of infants; and we have 
moreover, the authority of Dr. Chapman, in behalf of its useful- 
ness in this dangerous affection. I have employed this article in 
four or five instances, with a result sufficiently favorable, to induce 
me to believe, that considerable benefit may be derived from its 
use, provided the action of the liver has been excited by the pre- 
vious employment of mercurials. So long, however, as the evac- 
uations indicate the existence of functional torpor of the biliary 
organs, and there is reason to believe that the intestines are 
charged with fasculent matter, it will,* I am persuaded, be most 
prudent to abstain from this, and all other astringent substances. 
After the bowels have been thoroughly evacuated by calomel, 
and the alvine discharges assume a bilious appearance, and inca- 
cases of a chronic character, small doses of the acetate of lead, 
may be used with a favorable prospect of advantage. The. fourth 
of a grain of this article with an equal quantity of Dover's powdef 
should be given every two or three hours, and continued until the 
inordinate diarrhceal action of the bowels is checked* In the ad- 
vanced periods of the disease, I have occasionally procured con- 
siderable benefit, from a solution of the tartrate of iron. Forty, 
grains of this preparation, may be dissolved in two ounces of water, 
to which half an ounce of ginger syrup should be added. Of this 
from twenty to forty drops maybe given to an infant four or five times 
daily. Dr. Robert JacKson speaks very favorably of the use of 
finely powdered charcoal, in diseases of the intestinal canal at- 

* A Dissertation upon Cholera Infantum, &c. By James Mann, M. D. Vide a Re- 
view in New- York Mert. Repository, vol. ii. p. 309— for 1805, 



296 OF CHOLERA INFANTUM, 

tended with morbid secretions; and Dr. Condie, states, that he has 
used this article with much advantage, "in the latter stage of the 
disease, when it had become, in some degree, chronic, and the dis- 
charges, from the bowels were acrid, dark colored and offensive." 
From my own experience, 1 can say nothing of this remedy, but I 
do not doubt its occasional usefulness, under the circumstances just 
mentioned. From five to ten grains of the pulverized coal, in union 
with four or five grains of rhubarb and a grain of ipecacuanna may 
be given every three or four hours. 

When from the violence and rapidity of the disease, or from its 
long continuance, the exhaustion becomes very great, the extre- 
mities cold, and the pulse very small and feeble, internal as well 
as external stimulants become necessary. Stimulating frictions, 
wrappin'g the body in flannel wrung out of hot brandy and water, 
together with the use of wine-whey, milk punch, or a weak solu- 
tion of carbonate of ammonia, with an equal portion of the com- 
pound tincture of cinchona, are indispensable to support the sink- 
ing energies of the system. I have known, much benefit to 
result from the use of the tincture of cinnamon. From fifteen to 
twenty drops should, be administered in some mucilaginous fluid 
every four hours. 

In the advanced periods of the complaint, severe colic pains, 
from flatulent distention of the stomach and bowels frequently 
greatly harass the little patient. To relieve these pains, Dr. 
Condie strongly recommends a few drops of the spirits of tur- 
pentine; and my own experience enables me to speak favorably 
of this remedy. The juniper oil, also, is an excellent palliative, 
for this purpose. When given with sulphuric ether and laudanum, 
it seldom fails to procure, very considerable relief. From ten to 
fifteen . drops of the following solution, may be given three or 
four times daily.* 

After the disease has been, in a considerable degree subdued, 
and the alvine discharges, have assumed a natural appearance, 
recourse should next be had, to remedies calculated to invigorate 
the stomach and intestines. A decoction of blackberry root in 
milk, in the proportion of half an ounce of the root to a pint of 

* R- 01 juniper, 3ii. Sulph.JEther, gss. Tinct. Opii. gtt. lx. M. ft. 



OF CHOLERA INFANTUM. 297 

milk, often proves very useful at this advanced and declining 
stage of the disease. The common cretacious mixture, with the 
addition of a small portion of the tincture of kino, forms also, a 
very useful remedy for this purpose. But the remedy *I have 
found most beneficial, in restoring the tone of the alimentary 
canal, is a mixture of equal parts of lime water, and infusion of 
peruvian bark, with four or five drops of the tincture of kino, 
with each dose. The dose for an infant, is a dessert spoonful four 
or five times daily, mixed with a little barley water or solution 
of gum arabic. 

Throughout the whole course of the disease, particular atten- 
tion must be paid to the proper regulation of the diet. If the 
child is nourished at the breast, and the mother or nurse fur* 
nishes a sufficient supply of wholesome milk, no other nourish- 
ment whatever, should be allowed. If it has been weaned, great 
care must be taken that the food be of the simplest and blandest 
kinds possible. Boiled milk; liquid preparations of arrow-root, 
tapioca, sago, rice; thin oat meal gruel, barley water, or a solu* 
tion of gum arabic, are decidedly the most suitable articles of 
nourishment in every stage of cholera. In the chronic form of 
the disease, however, beef tea, or weak chicken broth, either by 
itself or mixed with some of the preceding articles, sometimes 
produces a favorable change in the state of the stomach and 
bowels. In cases of this kind, the little patient sometimes mani- 
fests a most urgent craving, for certain strong and stimulating 
articles of food, such as salted and smoked herring or shad, old 
and rancid bacon, salted beef, &c. whilst the stomach appears 
to loathe all the light and unirritating articles of nourishment, 
enumerated above. When this occurs, it will be proper too, 
cautiously to gratify the newly-awakened appetite, however, 
opposed to the ordinary dietetic rules the indulgence may appear 
to be. "I have seen many children recover," says Dr. Rush, 
" from being gratified in an inclination to eat salted fish, and the 
different kinds of salted meat. In some instances, they evince an 
appetite for butter, and the richest gravies of roasted meat, and 
eat them with obvious relief to all their symptoms." Without 
these strong instinctive calls of nature, however, it would be 
highly improper to allow such coarse articles of food — yet where 

2Q 



298 OF CHOLERA INFANTUM. 

the inclination for them, is distinctly manifested, it ought to be 
gratified, though always in a cautious manner. 

Nothing contributes more to the removal of this disease — more 
especially when it tends to a chronic form, than the enjoyment 
of the pure and salubrious air of the country. Whenever it is 
practicable the little patient ought to be removed into the coun- 
try; for this change is often sufficient to subdue the disease in a 
short time, without the aid of any other remedial means. If the 
circumstances do not admit of a removal from home to a suitable 
situation in the country, some advantage may be gained by carry- 
ing the patient about in the open and fresh air; and still more 
by frequent rides into the country in a carriage. 

As a preventive measure, residence, or at least daily gestation, 
in the pure air of the country has a most salutary influence. If 
this advantage cannot be procured, every other practicable means 
should be adopted, to protect the infant against the relaxing and 
enervating effects of a heated and confined air. The practice of 
keeping the windows and doors closed, at night, and placing the 
infant upon a soft feather bed, with an abundance of covering, 
during the warm months of summer, has a most pernicious effect. 
"Examine," says Dr. Parrish, "in the morning, a child who has 
passed the night thus confined. You will find him limber as a 
rag, exhausted by perspiration, wholly destitute of animation, 
without appetite, and on the very verge of cholera." To avoid 
these injurious effects, the doors of the infant's sleeping apartment 
should be open, and, if the room is large enough to prevent the 
current of night air, from passing immediately over the child, 
the windows, also, should be kept open, with the shutters closed. 
The child should sleep on a mattress, "or on blankets folded and laid 
upon the floor; and the covering ought to be light but comfortable." 
The use of the tepid bath, or frequent ablutions with cool water will 
assist materially in fortifying the infant's system, and lessening the 
liability to an attack of this disease. The respectable physician, 
whom I have just quoted, strongly recommends, allowing infants 
the free use of cool and fresh water, as a beverage during the 
heat of summer, as a prophylactic against this and other mala- 
dies; and I have not the slightest doubt of the entire propriety 
of this advice. The child should be daily carried out, into the 



OF CHOLERA INFANTUM. 299 

open air, and, if practicable, beyond the bounds of the city. All 
strong, flatulent, and indigestible articles of nourishment, should 
be carefully avoided. During the first year no nourishment is so 
congenial and appropriate as the mother's milk. Nourishment 
at the breast is particularly important during the active progress 
of dentition. If the child has been weaned, milk, preparations 
of arrow-root, tapioca, and sago — oat meal gruel, weak chicken 
broth, and beef-tea, constitute suitable articles of nourishment. 
Experience has shewn, that "the sucking of small pieces of salt 
meat — as ham, or dried beef," is often productive of manifest 
advantage. If the gums become inflamed and swollen they should 
be freely divided, down to the advancing teeth. Dr. Parrish 
speaks very favorably of the habitual use of aromatics, during 
the summer, as a means of guarding against the occurrence of 
this malady. He does not, however, advise, that they should 
be given, "indiscriminately to all children, during the summer." 
They are proper only in those cases, "in which a predisposition 
to cholera infantum exists." The daily use of moderate portions 
of ginger tea, or of a weak infusion of cinnamon, or of nutmeg, 
produces an excellent effect, in giving tone to the alimentary 
canal, and fortifying it against the influence of the usual exciting 
causes of this malady. I can say nothing from my own experi- 
ence of the effects of this practice; but it seems very probable 
that, where there is general languor, with a weak and inactive 
state of the digestive organs, considerable benefit may be derived 
from the judicious employment of the milder and more agreeable 
articles of this class of stimulants, The use of small portions of 
porter and water, has appeared to me very beneficial in feeble 
and relaxed infants, during the warm seasons, as preventive of 
bowel complaints. It is to be observed, however, that when the sys- 
tem is under the influence of painful dentition, where the pulse is 
contracted and irritated, and the head very hot, particularly when 
attended with great irritability and fretfulness of temper, all arti- 
cles of this kind are decidedly objectionable. It is only in cases 
of weakness and languor, accompanied with a feeble and relaxed 
state of the alimentary canal, and a sluggish state of the circula- 
tion, that they can be employed with propriety and advantage. 



300 REMITTENTS OF INFANTS. 



CHAPTER XXIV. 



OF THE REMITTENT FEVERS OF INFANTS. 

Children are subject to various modifications of remitting 
fever, which, in their phenomena, progress and causes, differ very 
materially from the ordinary remittent fever of adults. Authors 
have described this fever, under the titles of worm fever, the hec- 
tic of dentition, hectic of infants, and marasmus. Underwood 
gives a short description of four " kinds" of fever, peculiar to in- 
fancy and childhood, all of which are treated of by Butler, Pem- 
perton, Colley and others, under the general head of infantile 
remittent. Burns divides the remittents of children into two vari- 
eties — namely, that which occurs " in early infancy," and that 
which takes place after the process of primary dentition is com- 
pleted. This division is judicious and useful; for the cases that 
occur during dentition are usually characterized by some peculiar 
phenomena, and require corresponding modifications in the reme- 
dial treatment. 

I. Of the remittent fever of infants during dentition. — This mod- 
ification of infantile remittent, generally bears a close resemblance 
to the forming or initial stage of acute hydrocephalus, and 
indeed, there is not much difference between them; " for in both 
we have much cerebral irritation, and the difference is more in 
the result than in the early condition." 

The first manifestations of indisposition, generally, occur during 
the night. The infant is, unusually restless, and starts frequently 
in its sleep, as if from sudden fright, or it remains awake and ex- 
tremely fretful during the greater part of the night. Its skin is 
hot and dry, until towards morning, when a slight moisture breaks 
out about the head and chest. In the early part of the forenoon, 
the countenance is pale with an expression of suffering and dis- 
content, and the little patient ceases to evince its usual playful- 



REMITTENTS OF INFANTS. 301 

ness and interest in its toys. The pulse is always very frequent, 
and generally contracted and firm. In the afternoon the irrita- 
bility and fretfulness of temper increase, a circumscribed blush 
commonly occurs on one or both cheeks, the child is inclined to 
vomit, the frequency and tension of the pulse increase, the skin 
becomes hot, the urine is scanty and high colored, and in some 
instances so acrid, as to cause the infant to cry out with pain 
during micturition. A slight cough, with augmented secretion of 
bronchial mucus, generally supervenes after the disease has con- 
tinued for some days, and the bowels are irregular, mostly costive, 
while the alvine evacuations are extremely offensive, and of a 
muddy-brown or bright-green and curdled appearance. If the 
disease be not counteracted by suitable remedies, the febrile 
symptoms gradually increase. The exacerbations become more 
violent and protracted — during which the infant generally lies in 
a somnolent or drowsy state, with the eyes half open and turned 
upwards so as to conceal the cornea. If the disease continues, 
the remissions become shorter and Jess distinct, and the symptoms 
of cerebral irritation more and more conspicuous — the eyes 
acquiring a dull, heavy and slightly injected appearance, and the 
countenance an expression of surprise or stupor. By degrees 
symptoms of cerebral oppression or effusion ensue, and the child 
dies in a state of coma or a paroxysm of convulsions. In some 
instances, however, instead of these hydrocephalic symptoms, the 
little patient is gradually exhausted, " by the continuance of the 
fever, or, more quickly, by the accession of rapid and obstinate 
diarrhoea. 

If the disease is suffered to run on for six or seven days, it sel- 
dom terminates favorably before the end of the second week; and 
in some instances, after the violence of the disease has been sub- 
dued, a slow irritative fever continues for many weeks, or until 
the advancing teeth are completely protruded. In these pro* 
tracted cases, the infant is pale, languid, extremely fretful and 
restless, with irregular bowels, and a frequent and very small 
pulse. The head is, usually, very warm, while the hands and 
feet are often cold; and in some instances, the face acquires a 
bloated or tumid appearance. Not unfrequently, however, the 
disease begins to subside as early as the fourth or fifth day. The 



302 REMITTENTS OF INFANTS. 

exacerbations become shorter and less severe; the child rests 
better at night, and the skin becomes cooler and more uniformly 
moist and soft. The declension of the disease is often attended 
with moderate diarrhoea, or a profuse secretion of saliva, and 
" we sometimes find that, at this time, one or more teeth have 
made their appearance." 

This modification of infantile remittent fever, appears to be an 
irritative fever depending on difficult dentition, modified and 
aggravated by gastro-intestinal irritation or a disordered condi- 
tion of the chylopoictic organs. Throughout the whole course 
of the disease, distinct manifestations of cerebral irritation are 
present, and in many instances, the brain is obviously in a state 
of erethism for many days, before the disease assumes a decidedly 
febrile character. The disease very rarely, if ever, occurs, 
when the advance of the teeth through the gums is attended 
with a profuse secretion of saliva or a moderate diarrhoea. Cos- 
tiveness and a dry and unusually warm condition of the mouth, 
are among the most constant symptoms of the early stage of this 
disease; and in most instances there are very obvious indications 
of irritation in the gums. 

Treatment. — The mouth should always be carefully inspected, 
and if the gums are in the slightest degree swollen or inflamed, 
they should be freely divided. The irritated and irritating con- 
tents of the bowels must be evacuated, and remedies prescribed 
for correcting the biliary and intestinal secretions. For this 
purpose, one or two grains of calomel should be administered, so 
as to procure free purging. If the calomel is slow in operating, 
or inefficient, it should be followed, in three or four hours by one 
or two teaspoonfuls of castor oil or of the syrup of rhubarb. 
After the intestines have been, thus, well evacuated, they must 
be kept in a loose state by the regular administration of very 
small doses of calomel in union with ipecacuanna. The fourth 
of a grain of the former with half a grain of the latter, may be 
given four times daily, and if these do not keep the bowels suffi- 
ciently open, their aperient operation ought to be promoted, by 
a suitable portion of magnesia, castor oil, or rhubarb, once every 
twenty-four hours. If the child is robust and plethoric much 



REMITTENTS OF INFANTS. 303 

advantage may be derived from the abstraction of an ounce or 
two of blood, either with the lancet, or by leeching about the 
head; and when the pulse continues to be active and tense, and 
there are decided indications of cerebral irritation, the bleeding 
ought to be repeated until an evident impression is made on the 
action of the heart and arteries. After the violence of the reac- 
tion has been, in some degree, moderated, by evacuants, a blister 
should be applied to the back of the neck. When the head is 
very hot and a tendency to stupor occurs, cold applications to 
the head are very useful; and, if at the same time the hands and 
feet are cold, sinapisms or vesicatories may be advantageously 
applied, to the wrists and soles of the feet, or above the ankles. 
Some benefit may also be obtained from the use of diaphoretic 
remedies. The following mixtures are well adapted for this 
purpose.* When the stomach is not too irritable, tart, emetic, in 
minute doses, is calculated to operate very beneficially in cases 
of this kind. When there is much cerebral irritation with an 
active and firm pulse, this article may, in general be given in 
pretty active doses, without exciting much vomiting. I have 
often given the eighth of a grain, every two or three hours, to 
infants laboring under this complaint, with but little or no vomit- 
ing, and generally, with a decided sedative impression on the 
action of the heart and arteries. The effects of opium in this 
complaint are very uncertain. In some instances, it operates 
very injuriously, — increasing the determination of blood to the 
brain, and hastening the supervention of cerebral inflammation 
and oppression. In other cases, its effects are highly beneficial. 
It moderates the general irritative condition of the patient, 
lessens the frequency and tension of the pulse, and removes all 
the alarming symptoms of approaching inflammation and effusion 
within the head. It is, indeed, often extremely difficult, to 
determine satisfactorily, merely from the symptoms, whether this 
narcotic be proper or not. When the symptoms indicate a strong 
tendency to, or the actual presence of inflammation of the brain, — 

* R. Pulv. Extract Glycyrrh. 3ii; Pulv. Nitrat Potass Qi; Aq. fontanae Jii; Vin. 
Antimon. gtt. xl ; M. Dose, a teaspoonful every two or three hours. 

* R- Spirit Minderiri, gii; Syrup Limonis Ji; Vin. Antimonii gtt. 40: Spirit Nitri. 
Dulc. 3' ss - M- ft. Dose, a teaspoonful every three hours. 



304 REMITTENTS OF INFANTS. 

that is, when the child rolls its head about on the pillow, keeps 
its hands pressed on the forehead, shuns the light, starts and 
screams out suddenly, has a discontented and frowning expression 
of the countenance and is withal of a robust and plethoric 
habit, the use of opium, will probably result in serious injury to 
the patient. When, on the other hand, the general habit is 
feeble, or free evacuations have been premised, and the little 
patient is restless, irritable and fretful, with a pale and languid 
countenance, we may, with but little risk of injury resort to this 
remedy; and its effects in cases of this kind, are often highly 
favorable. Even in cases, however, where there was much 
reason to apprehend the existence or near approach of cerebral 
inflammation, I have known the most decided benefit to result 
from the regular exhibition of small closes of Dover's powders in 
union with calomel. Free purging, should always be premised; 
and when the pulse is active and tense, as it almost always is, 
blood ought to be efficiently abstracted, before opiates are 
resorted to. 

The best form, perhaps for administering opium in this disease, 
is in combination with calomel and pulvis antimonialis. The 
twentieth of a grain of this narcotic, with a fourth of a grain of 
calomel and half a grain of antimonial powder, may be given 
every three or four hours. Burns recommends the use of a few 
drops of the tincture of hyoscyamus, with a saline julep, to mo- 
derate the general irritation. I have used the tincture of bella- 
donna for this purpose with evident benefit. Three or four drops 
given, twice or thrice daily, frequently produces an obvious 
abatement of the irritability and restlessness of the little patient. 
The daily employment of the tepid bath, is calculated to do con- 
siderable good, in moderate cases of the complaint by relaxing 
the skin, and allaying irritation. It should be used during the 
febrile exacerbation, and the child must not be suffered to re- 
main in the bath longer than about ten minutes. This remedy 
is particularly useful in cases, depending, mainly, on difficult 
dentition. It seldom fails to tranquillize the system, when used 
in instances of this kind. 

If, after the acute spmptoms have gone off, the disease continues 
in a chronic form, the child being pale, languid, emaciated, fretful, 



REMITTENTS OF INFANTS. 305 

and restless during the night, with a small and thready pulse, 
and a disordered state of the bowels, gestation in the open air of 
the country, often proves highly beneficial. In this stage of the 
disease, I have derived very considerable advantage, from the 
use of Dr. W, Fordyce's p%dvis antihedicus infantum — consisting of 
from ten to twenty grains of the sulphate of potash, in union with from 
five to eight grains of powdered rhubarb, according to the age of the 
child. Such a portion should be given every morning, until the 
alvine evacuations assume a more natural appearance, and the 
action of the bowels become regular. A few grains of Dover 
powder, with the fourth of a grain of calomel should be given 
every evening. In cases of this kind, the tincture of hyoscyamus 
and belladonna are, in general peculiarly beneficial. Three 
drops, in a teaspoonful of spirit Minderiri sweetened with lemon 
or ginger syrup, should be given three or four times daily. 

The infant's diet must be carefully regulated throughout the 
whole course of the disease. Animal food of every kind is deci- 
dedly objectionable. If the child is still nourished at the breast, 
and the mother or nurse furnish a sufficient supply of good milk, 
no other nourishment is necessary. If there is a deficiency of milk, 
or if the child has been weaned, it should be confined to the use 
of thin preparations of arrow-root, sago, and oat-meal, and a mix- 
ture of three parts of cow's milk and one of water. During conva- 
lescence, or in a low and chronic state of the disease, weak beef 
or chicken tea may be allowed, along with the farinacious prepa- 
rations just mentioned. Equal parts of thin arrow-root and 
chicken tea forms a good nourishment in this condition of the 
patient. 

II. Of the remittent fever of children after dentition. — This mod- 
ification of remitting fever, very rarely occurs previous to the 
second year, and is evidently intimately associated with derange- 
ment of the chylopoictic system, or gastro-intestinal irritation. In 
some instances the disease comes on suddenly, in consequence of 
overloading the stomach, or of the use of irritating and indigesti- 
ble articles of nourishment. The attack generally occurs at 
night. The child becomes pale and cold or is seized with chil- 
liness, which, in most cases, is soon followed by nausea and vomit- 

2R 



306 REMITTENTS OF INFANTS. 

ing. Febrile reaction speedily ensues; the skin becomes ex- 
tremely warm and dry, the pulse very frequent and strong, and the 
little patient is very restless, thirsty, and usually complains of 
headache, and severe transient pains in the stomach. Towards 
morning, a slight perspiration breaks out about the head and 
chest, and the febrile symptoms remit, leaving the child pale and 
languid, without the least appetite for food. In the course of 
the morning generally about ten or eleven o'clock, the child's 
countenance becomes contracted and very pale, its hands and feet 
are cold, nausea, and generally vomiting occur, and a second febrile 
exacerbation ensues, which usually continues until the following 
morning, when a remission takes place, which, if the disease is not 
arrested, is again succeeded by a paroxysm of fever. During 
the first ten or twelve hours, the tongue is generally clean; 
but in the course of the second day, it becomes covered with a 
white fur, which soon acquires a brown appearance, and in pro- 
tracted cases, at last becomes almost black. The bowels are 
generally extremely torpid, the pulse though frequent, full and 
quick, is seldom firm or tense; the thirst is always very great, 
and the child complains of almost constant headache. During 
the first two or three days, nausea and vomiting occur repeatedly, 
and the child, usually, feels somewhat relieved, particularly of 
the headache, after each spell of vomiting. After the disease 
has continued for some days, the little patient is apt to remain in 
a drowsy state during the febrile exacerbations, and is apt to 
pick the lips and nose with his fingers, until they become quite 
sore. 

Cases of this kind, if not subdued, at an early period, often 
continue for several weeks. The abdomen, at last, becomes 
tumid and distended with wind, or tympanitic; a black sordes 
collects about the lips and teeth; if a purgative is given, a reddish, 
or muddy water passes off, mixed with small masses of solid fecu- 
lent matter and small flakes of mucus, or the discharges are 
black and glairy, or green and curdled. 

Much more frequently, however, this variety of fever comes on 
in a gradual manner. The child begins to droop; its counte- 
nance is pale, with an expression of languor and uneasiness, the 
pulse frequent and small, the hands and feet cool and the head 



REMITTENTS OF INFANTS. 307 

and body generally unusually warm. In the afternoon — slight 
febrile symptoms occur, and in many instances, several attacks of 
feverishness take place in the course of the day, during which, 
the child, generally lies down, and falls into a heavy and dis- 
turbed sleep. In the intervals of these slight febrile exacerba- 
tions, the little patient appears to be " tolerably well, but is 
easily put out of temper," and seems to feel a general soreness 
of the flesh, causing him to fret and cry out as if in pain when 
touched or lifted. The tongue is covered with a thin white fur, the 
thirst is moderate, and the appetite, in general, depressed and 
capricious. The bowels are usually torpid, though in some 
cases, the stools are frequent, liquid and very offensive. The 
evacuations are seldom very bilious, and in many instances, there 
is a manifest deficiency of bile. These symptoms, generally, 
continue for eight or ten days, when all at once, a severe parox- 
ysm of fever, occurs, preceded by chilliness or shivering attended 
commonly with nausea and vomiting. The pulse becomes very 
frequent, full, and somewhat tense, the countenance flushed, and 
the drowsiness is much increased. The patient seldom com- 
plains of pain in any part, except occasionally, of transient and 
sometimes very severe pains in the abdomen. If, however, pain 
does occur in the head, which is by no means common, it is 
usually "both violent and permanent." One of the most con- 
stant symptoms attending the fully developed state of this fever, 
is, an incessant picking of the lips, nose, and angles of the eyes. 
When the disease has advanced to this stage, there is an 
entire loathing of every kind of food; digestion appears to be 
wholly suspended, and the tongue becomes covered with a thick 
fur, which soon acquires a dark brown color. The intestines are, 
almost invariably, exceedingly torpid, and the alvine evacuations 
are " without the smallest resemblance either in appearance or 
smell, to those fasces, where the power of digestion has been 
exerted." They are dark or black and glairy, or thin and 
foamy, resembling yeast, or curdled and dark green, with a very 
peculiar offensive smell; and in some instances, they are whitish 
or clay-colored, " indicating a deficiency of bile." (Burns.) As 
the disease advances, delirium occurs during the exacerbations, 
and in the last stage, it sometimes continues for two or three 



308 REMITTENTS OF INFANTS. 

days, with but slight and temporary abatements in the morning. 
In general, however, the patient may be roused from the deli- 
rium for a minute or two, so as to answer questions distinctly. 
At first the febrile exacerbations occur only in the afternoon; 
but by degrees, they become prolonged, so as to leave but very 
short and imperfect remissions between them. During the 
delirium, the child picks at the bed-clothes, is very restless, 
starts up suddenly, and moans and sighs almost constantly; and 
in severe cases it has fits of violent screaming and agitation. 
Towards the fatal termination of the disease, convulsions, paraly- 
sis of one side, strabismus, or deep coma sometimes occurs. The 
abdomen, generally, becomes tumid and tense or tympanitic, in 
the advanced stages of the disease, and, in some instances a total 
retention of the urine takes place. 

After this fever is once fully developed, it seldom terminates 
before the seventh or eighth day, and, most frequently, continues 
for several weeks. When paralysis, strabismus, or convulsions 
occur, there can be but very slight hopes of a favorable termina- 
tion. These symptoms are, however, not always indicative of a 
fatal result, for patients sometimes recover, after all the usual 
signs of cerebral effusion have supervened. Nevertheless, when 
symptoms of this kind are attended with a bloated and tense 
state of the abdomen, and watery discharges from the bowels, 
all hopes of a fortunate termination are in vain. - 

In some cases, this fever never becomes very violent, but 
creeps on in a slow or chronic form for three or four weeks. In 
instances of this kind, there is always a considerable remission 
in the morning, even in the advanced stages of the complaint, 
and the exacerbations are scarcely ever attended with delirium 
or very great drowsiness. At first the appetite is depressed, but 
in the course of four or five days, it generally improves, and the 
child will eat, pretty freely, during the remissions. The alvine 
evacuations, however, exhibit a very unnatural appearance, and 
are extremely offensive. The intestines become greatly dis- 
tended with wind so as to give a tumid and drum-like elasticity 
to the abdomen. Evacuation goes on rapidly, and the counte- 
nance acquires a very pale and haggard appearance. The brain, 
at last, sometimes becomes affected; the child becomes more and 



REMITTENTS OF INFANTS. 309 

more fretful during the remissions and drowsy in the exacerba- 
tions. It starts and screams out in its sleep, grinds its teeth, turns 
the eyes up so as to hide the cornea, and finally sinks into a state 
of constant somnolency, coma, attended," perhaps, with paralysis 
and convulsions. 

Dr. Underwood mentions a modification of this fever, the most 
remarkable symptom of which, he says, is the occurrence of "in- 
flamed and sometimes painful tumours," seated chiefly on the in- 
ferior extremities, more especially along the spine of the tibiae. 
They acquire the size of a nutmeg, in the course of the second 
day, and soon become soft, resembling small abscesses. They do 
not, however, suppurate, or contain matter, and generally disap- 
pear again, in four or five days. I have met with a few instances 
of this kind, and have not found them to be attended with any 
peculiar difficulty or obstinacy. 

It is often extremely difficult to distinguish infantile remittent 
fever from acute hydrocephalus, and in some cases, indeed, there 
exists no essential difference between them — the causes and pro- 
minent pathological conditions being in every important respect 
of the same nature. In many instances, however, infantile re- 
mittent fever, though similar in appearance, with hydrocephalus, 
is nevertheless, sufficiently distinct from it, to render a correct di- 
agnosis between them of considerable consequence, both in a 
prognostic and remedial point of view. The following circum- 
stances, will in general enable us to distinguish the two com- 
plaints from each other. In hydrocephalus, the face is frequently 
flushed, and the child tosses its hands above the head, or presses 
them on the forehead. In infantile remittent, the countenance, 
though occasionally flushed is generally pale and leaden or of a 
dingy pallid appearance; and the little patient is constantly pick- 
ing the lips and nose with the fingers. In hydrocephalus head- 
ache is an almost constant symptom, and is often so acute as to 
cause the child to cry out "oh my head." It is, also, usually 
connected with much intolerance of light. In infantile remit- 
tent, headache rarely occurs, and when it does come on it is usu- 
ally transient and connected with nausea or vomiting. In the 
early stage of hydrocephalus there is generally frequent vomiting 
particularly when the child is raised into a sitting or erect pos- 



310 REMITTENTS OF INFANTS. 

ture. In remittent fever, this is much less common, nor is apt to 
occur when the patient's head is suddenly raised. In the former 
affection, the abdomen almost always becomes flattened; whereas 
in infantile remittent fever, the abdomen becomes tumid, tense 
and elastic or hard. Goelis insists particularly on the impor- 
tance of this circumstance, as a diagnostic sign in these affections. 
In idiopathic hydrocephalus, diarrhoea or looseness of the bowels 
scarcely ever occurs, in the early stage of the disease. In remit- 
tent fever, diarrhoea is no uncommon symptom, in the commence- 
ment of the complaint. In the former affection, the nostrils and 
mouth are dry, in the latter, they are generally moist with mucus, 
and the secretion of saliva is increased. The delirium of hydro- 
cephalus, is generally more constant, and, after it has continued 
for some time, the patient cannot be roused from it, as in the re- 
mitting fever. The pulse also, is much more irregular and tense, 
and in the advanced stage, when stupor or coma is present, it, 
usually, becomes slow and intermittent. There is strabismus, 
deep sighing, sudden and violent screaming, and in most cases, 
constant rolling of the head, and frequent grinding of the teeth. 
In the infantile remittent the breath is often offensive, which is 
rarely the case in idiopathic hydrocephalus. In the advanced 
stages of the former complaint, there is almost invariably a great 
aversion to every kind of food; but in the latter disease, the pa- 
tient frequently takes without reluctance, whatever is offered, 
"apparently making no distinction between what is palatable 
and what is nauseous." The alvine evacuation, will, also, aid 
us in forming a satisfactory diagnosis. In the fever under consid- 
eration the stools are always "remarkably changed from their natu- 
ral appearance." They are sometimes perfectly black and glairy, 
resembling tar, with a smell that has been compared to putrid mud ; 
at other times they consist of a dark green fluid mixed with shreds 
and flocculi of mucus. In hydrocephalus, the stools are, at first 
often light colored, and after the disease has continued for four or 
five days or longer, they frequently exhibit a foamy and light 
green appearance, of the consistence of thick syrup or pap, re- 
sembling chopped spinage. If after an attack of convulsions, the 
mental faculties are restored ''and the history of the disease ac- 
cord with the symptoms above described, we may securely pro- 



REMITTENTS OF INFANTS. 311 

nounce that the head is not the source of the convulsions, but that it 
is merely a symptom of intestinal irritation" (Pemperton). It may 
be observed, that when the symptoms are so ambiguous as to 
render it doubtful whether they depend on meningeal inflamma- 
tion and effusion, or on mere sympathetic irritation and vascular 
tergescence of the brain, the exact diagnosis cannot be of mate- 
rial service in the treatment, since the same means are indicated, 
and would be used whether the cerebral affection be primary and 
independent, or secondary and symptomatic of gastro-intestinal 
irritation. 

The usual exciting causes of the present variety of infantile 
remittent fever, are, improper food, a torpid state of the bowels, 
worms, vitiated or acrid secretions from the liver, cold and moist- 
ure, dentition, and perhaps deficient attention to cleanliness, pure 
air, and exercise. All who have written on this disease agree, in 
referring it to a primary irritation located in the stomach and 
bowels, with disordered functions of the biliary organs. Mr. 
Colley thinks, that the primary disorder consists in torpor or de- 
fective action of "some part, or of the whole of the chylopoictic 
system, and generally of the liver stomach and intestines." It is, 
indeed, sufficiently evident that both the stomach and bowels 
are extremely inactive, in this malady; digestion is soon entirely 
suspended; and, in the early periods of the complaint, the alvine 
evacuations often, indicate a deficient secretion of bile. In con- 
sequence of this torpid state of chylopoictic organs, the contents 
of the intestines, probably, undergo such chemical changes "as to 
become the source of extreme irritation" to the mucous membrane 
of the alimentary canal. The vitiated secretions from the liver 
and intestinal glands, also, contribute to the same injurious result; 
and it is not improbable that the blood itself, may undergo some 
morbid change, in consequence of the absorption of chyle imper- 
fectly elaborated, and vitiated by the depraved fluids generated 
in the alimentary canal. The tendency of gastro-intestinal irrita- 
tion to excite disease in other organs, particularly in the brain, is 
well known. Dr. Burns observes, that "we are not yet enabled 
to say, what particular mode of irritation gives rise to the dif- 
ferent modifications of phenomena; or why, in one case the same 
apparent exciting cause should produce spasmodic, and in another 



312 REMITTENTS OF INFANTS. 

febrile affections." Broussais has thrown some light on this inter- 
esting subject. It would appear, that when the local irritation is 
purely nervous, the sympathetic consequences will be confined to 
the nervous system; but when the local irritation involves, also, 
the capillary blood-vessels, that is, when there is inflammatory 
irritation, the secondary effects will be febrile and inflammatory. 
Thus if some very indigestible substance be taken into the sto- 
mach, the immediate impression on the gastric nerves will be 
communicated to the brain, and convulsions or some other spas- 
modic or purely nervous affection will probably occur. If the 
substance remain long enough to excite local vascular irritation 
in the stomach or bowels, the sympathetic consequences will be 
febrile. 

Treatment. — From the symptoms, causes and pathological cha- 
racter of this disease, it is obvious, that the principal objects to 
be kept in view in the treatment, are, to clear the bowels of their 
vitiated and irritating contents; to correct the biliary and intesti- 
nal secretions; to obviate cerebral irritation; and finally, to mod- 
erate the excessive action of the heart and arteries. In cases that 
come on suddenly after eating some improper substances, or over- 
loading the stomach, the immediate exhibition of an emetic, fol- 
lowed, after it has ceased to operate, by an active purge, will in 
general suffice to put a speedy termination to the disease. The 
irritating causes are thus removed out of the alimentary canal, 
before they have excited a fixed inflammatory irritation, and the 
disease consequently speedily subsides. If, however, the offensive 
substances received into the stomach are peculiarly irritating, 
and a predisposition exists to inflammatory irritation in the mu- 
cous membrane of the alimentary canal, or in some other organ; 
or if proper evacuants be neglected soon after the accession of 
the fever, the disease will be apt to continue for many days, how- 
ever diligently the stomach and bowels be evacuated by emetics 
and purgatives. It is generally very difficult to procure free 
evacuations from the intestines in cases of this kind, particularly 
when the disease has been excited by hard and very indigestible 
substances, such as cherry stones, orange peel, raisins, almonds, 
&c. In some instances, portions of the irritating substances are 



REMITTENTS OF INFANTS. 313 

retained, and discharged in an imperfectly digested condition, 
four or five days after they were taken into the stomach, although 
the bowels are daily evacuated by active purgatives. If the in- 
testines resist the free operation of purgatives, active clysters 
ought to be administered to procure the desired effect. When 
the pulse is full and active, and particularly when the face is flush- 
ed and the head very hot, much benefit may be derived from 
bloodletting. It would seem that the intestinal torpor, in this 
complaint, frequently depends, in a considerable degree, on vas- 
cular fulness in the brain; and hence an efficient abstraction of 
blood, almost always increases the susceptibility of the bowels to 
the operation of aperients. It is not, however, merely on this 
account, that bleeding is proper, during the exacerbations of this 
fever. When the pulse is full and strong, the momentum of the 
circulation should be speedily moderated, with the view of obvi- 
ating local inflammation and dangerous congestion. 

In the second modification of the disease — that is, in those cases 
that come on gradually, emetics are much less important reme- 
dies, than in the preceding variety, — brought on suddenly, in con- 
sequence of the reception of irritating substances into the sto- 
mach. Nevertheless, if in the commencement of the disease there 
is reason to suspect the existence of offensive materials in the 
primas vias, more especially when the patient is affected with 
nausea or retching, the exhibition of a gentle emetic, generally 
produces a very beneficial effect. The bowels should, in the first 
place, be thoroughly evacuated, and aftewards kept in a loose 
state by the regular employment of suitable aperients. It is often 
as difficult to procure free evacuations from the bowels in this as 
in the preceding modification of the disease. In general, how- 
ever, sufficient purging may be excited by the administration of 
from six to eight grains of calomel, followed, in four or five hours, 
by a full dose of castor oil, or of infusion of senna and manna. In 
some instances of extreme torpor of the bowels in this affection, 
I have obtained very copious purging, by the employment of cas- 
tor oil in union with the spirits of turpentine, some hours after the 
exhibition of a dose of calomel. A dessert spoonful of the oil 
with twenty or thirty drops of the turpentine may be given every 
hour, until active purging is produced. Calomel, however, both 

2S 



314 REMITTENTS OF INFANTS. 

as a purgative and an alterative, is, undoubtedly, the most impor- 
tant remedy we possess in the treatment of this malady. After 
the alimentary canal has been well evacuated, this article ought 
to be regularly employed with a view to its constitutional or alter- 
ative influence, as well as to its aperient operation. Whether 
the liver be torpid or otherwise, it is quite certain that its func- 
tions are much disordered; and, until the morbid condition of this 
important organ is improved, no favorable change can take place 
in the general state of the disease. With this view, calomel 
should be exhibited, in small doses, three or four times daily, and 
its laxative effects promoted by the occasional administration of a 
dose of castor oil, or of epsom salts. It may be very advantage- 
ously given in union with small portions of ipecacuanna or of the 
pulvis antimonialis. I have generally prescribed a grain of calo- 
mel with half a grain of the antimonial powder, three times daily; 
and, on the following morning one or two drachms of epsom salts, 
or a few teaspoonfuls of castor oil. This course should be pur- 
sued until the alvine evacuations begin to exhibit a more natural 
appearance, after which the calomel must be given at more 
remote intervals, or wholly laid aside. In general more benefit 
may be derived from small and repeated doses of calomel than 
from large ones less frequently administered. Although purga- 
tives are always decidedly indicated in the treatment of this 
affection, yet very active purging, after the bowels have been 
freely evacuated, is, as a general rule, by no means advisable. The 
daily employment of drastic, or very active purgative remedies, is 
apt to give rise to inflammatory irritation of the mucous mem- 
brane of the bowels, attended with muddy or reddish watery 
stools, and a tender, swollen and tympanitic state of the abdomen. 
Two or three alvine evacuations, in the course of twenty four 
hours, are sufficient to prevent any injurious accumulation of 
acrid or vitiated secretions. After the disease has continued for 
two or three days, and the fasculent contents of the intestines 
have been well evacuated, the milder purgatives, only, ought to 
be employed, in the way mentioned above. If these do not pro- 
cure sufficient discharges, their operation on the bowels ought to 
be assisted by active clysters. 

If in the commencement of the fever, the pulse is full, active 



REMITTENTS OF INFANTS. 315 

and firm, more especially, when the child is of a robust and pleth- 
oric habit, or when there are decided indications of strong san- 
guineous congestion, and irritation in the brain, blood ought to 
be abstracted, either with the lancet or by leeching. Even in 
the advanced stages of the disease, blood-letting may sometimes 
be resorted to with much advantage, when the head is much 
affected and the pulse is still active and tense. If, after the dis- 
ease has continued for five or six days, the pulse continues to be 
full and pretty active during the exacerbations, the abstraction of 
three or four ounces of blood, seldom fails to make a favorable 
impression on the disease. When strong delirium or a state of 
stupor supervene, and the momentum of the general circulation 
has been moderated, much benefit may occasionally be derived 
from leeching behind the ears or on the temples. In general, 
however, more advantage may be obtained, under these circum- 
stances, from cold applications to the head, than from local de- 
pletion. I have frequently known, the symptoms of cerebral irri- 
tation and congestion in cases of this kind, speedily and very 
greatly moderated by the continued application of cold water or 
ice to the top and forepart of the head. If the feet are cool, 
which, in the latter period of the disease is sometimes the case, 
they ought to be excited by stimulating frictions or by warm ap- 
plications, at the same time that cold is applied to the head. 

Besides the remedies already mentioned, diaphoretics also, are 
very useful means for reducing the febrile reaction. The skin is 
generally obstinately dry and very hot; and a free action of the 
cutaneous exhalents is almost invariably attended with obvious 
abatement of the general febrile irritation. A simple solution of 
tartar emetic in water, or the antimonial wine, given in small 
but repeated doses so as to keep up a slight degree of nausea, will 
frequently do considerable good. I have often employed the 
following mixtures with unequivocal benefit.* To a child of from 
three to six years old a dessert spoonful should be given every two 
hours during the exacerbations of the fever. A mixture of spirit. 

* R Nitrat potassae 9ii; pulv. extract, glycyrrh. 3ii; tart, antimonii, gr. i; spirit, nit. 
dulc. 3ii; aq. fontanae giv. M. ft. 

R Muriat. amnion. 3' ; or pulv. extract, glycyrrh. 3iii ; vin. antimon. 3 1 ' > a0 »* fonta- 
nae giv. M. ft. 



316 REMITTENTS OF INFANTS. 

menderiri, and the sweet spirits of nitre, in the proportion of an 
ounce of the former to a drachm of the latter, and sweetened with 
lemon syrup, forms also an excellent diaphoretic, in this complaint. 
One or two teaspoonfuls should be given, every two or three 
hours, according to the age of the patient. If, after the violence 
of the febrile reaction has been moderated, the brain continues to 
be in an irritated or congested condition, that is, if much delirium 
or stupor be present, blisters applied to the back of the neck, at 
the same time, that cold applications are made to the head, will 
sometimes procure very considerable relief. 

It is often very difficult to determine whether the manifestations 
of cerebral disturbance arise from incipient inflammation, or from 
mere sympathetic irritation of the brain. If the former be the 
case, opiates, are of course wholly inadmissible; but, in instances 
of the latter condition, they often produce a highly salutary effect. 
In general, when at an advanced period of the disease, the deli- 
rium and cerebral disturbance is associated with a small, frequent 
and feeble pulse, a pale and sunken countenance, great jactitation 
and cool hands and feet, and especially when with these symptoms 
the patient can be roused from his stupor or delirium, opium may 
be employed with a prospect of much advantage. The best mode 
of using this narcotic is in the form of Dover's powder, in union 
with small portions of calomel. I have in some instances derived 
very great benefit from the administration of this remedy, ingrain 
doses repeated every three or four hours. When the cerebral dis- 
turbance is entirely irritative and symptomatic of gastro-intestinal 
irritation, the pulse becomes softer and slower, the skin moist and 
of a natural temperature, and the patient falls into an easy and 
sound sleep, as soon as the system is under the influence of the 
opium. When he awakens his mind is usually much tranquillized, 
and the whole aspect of the disease is sometimes changed for the 
better. In the latter period of the disease, when the fever is about 
subsiding, the patient, though not distinctly delirious, is occasion- 
ally extremely restless, and unable to obtain any sleep during the 
night. In instances of this kind, two or three grains of Dover's 
powder, given in the evening, generally produces a very soothing 
effect. It must be particularly observed however, that, although 
often highly beneficial in the advanced periods of the disease, 



REMITTENTS OF INFANTS. 317 

opium can very rarely be employed at an early stage, or before 
the febrile reaction has been considerably moderated by evacuants 
without incurring much risk of serious injury. In feeble and sick- 
ly children, I have occasionally administered a few grains of this 
anodyne, after the free operation of a purge, with evident advan- 
tage, at an early period of the complaint. In these cases, how- 
ever, the face was not flushed and the patient was very restless 
instead of drowsy, as is usually the case, during the exacerbations. 

When the abdomen becomes tumid and tender to pressure, the 
application of a few leeches to the epigastrium generally produces 
a very good effect. A large emolientpoultice laid over the whole 
abdomen, may also be resorted to, with much advantage in cases 
of this kind. The abdominal tumor in such cases, arises from 
flatulent distention of the bowels; and hence the expulsion of the 
confined flatus, frequently affords immediate relief. For this pur- 
pose injections of a watery solution of assafoetida, may sometimes 
be used with considerable benefit; but the remedy which has most 
frequently succeeded, in my hands, in reducing the abdominal 
distention, is the spirits of turpentine, administered internally, in 
doses of from eight to twelve drops three or four times daily. 
In very protracted cases, when the system is much prostrated and 
the bowels are in an irritated and tympanitic condition this 
article is indeed a very excellent remedy. It not only excites the 
bowels to contract, and to expel the confined wind, but it often 
exerts an evident beneficial influence on the intestinal secretions, 
and, it would seem, on the irritation of the mucous membrane of 
the stomach and bowels. 

After the disease has been in a great measure subdued and the 
alvine evacuations have acquired a natural appearance, mild tonics 
may sometimes be used with considerable benefit, during conval- 
escence. A weak infusion of bark, or of Colombo, will answer 
well for this purpose. I have in several instances used finely pow- 
dered charcoal, in union with powdered ginger, with very obvious 
benefit. From ten to fifteen grains of the former, to six or eight 
grains of the latter article, may be given three or four times 
daily. 

The diet ought to be of the lightest and most unirritating kind 
possible. During the active stages of the disease, toast water, 



318 OF CATARRH. FEVER. 

thin barley water, or rice water, will be sufficient. Every kind 
of solid food must be rigidly prohibited. For drink, the patient 
may use weak lemonade, toast water, and occasionally a table 
spoonful or two, of fresh water. During convalescence, chicken, 
lamb, or mutton broth, boiled rice, arrow root &c. will be 
proper. 



CHAPTER XXIV. 



CATARRH. CATARRHAL FEVER. 



Catarrhal affections under various forms and grades of vio- 
lence, are among the most common diseases of infancy and 
childhood. These complaints are particularly apt to occur 
during raw, variable, and humid weather, and hence they are 
most frequently met with in the spring and winter, more especi- 
ally when the latter season is moist and open. It is also, apt to 
occur during summer, when after a long spell of damp and clear 
weather, the atmosphere suddenly becomes dry and very hot. 
Catarrhal fever sometimes prevails epidemically, and the disease 
has been known to confine itself, in a great measure, to children. 
An epidemic of this kind occurred throughout the eastern states 
in 1824, in which by far the greater number of cases were 
among children. 

This malady is characterized by fever, cough, slight hoarseness, 
some difficulty of breathing, running at the nose, sneezing, and 
that peculiar watery appearance of the eyes which occurs in the 
commencement of measles. The disease begins with a slight 
feeling of chilliness, and occasionally with a distinctly formed 
chill. The hands and feet become cold, the whole surface of the 
body pale and contracted, and the patient appears languid and 
drowsy. This state of depression frequently continues for a 
whole day before the febrile reaction is fully developed. In 



OF CATARRH. FEVER. 319 

many instances, however, the fever supervenes in a very short 
time after the first feelings of indisposition. The patient com- 
plains of aching pains in the extremities and back, the pulse be- 
comes frequent, somewhat tense and generally full, the cheeks 
flushed, the eyes suffused with tears, and a thin transparent fluid 
usually issues from the nose attended in the commencement with 
frequent sneezing. The skin is dry and husky, though seldom 
much above the natural temperature. The bowels are torpid, 
and the urine scanty and high-colored; and, in many instances 
the alvine evacuations, during the first few days, manifest a defi- 
cient secretion, and sometimes an entire absence of bile. In 
some cases, cough with slight hoarseness, is one of the earliest 
symptoms; more frequently, however, the cough does not come 
on until the fever is fully developed, and often not until the dis- 
ease has continued for two or three days. The breathing is not 
often much oppressed in the early periods of the disease, though 
frequently attended with considerable rattling in the trachea. In 
severe cases, however, respiration is frequently difficult and 
wheezing, almost as soon as the fever is developed, owing to the 
abundant secretion of mucus into the air cells. This is most apt 
to be the case in infants, who, from not making any efforts to 
relieve the lungs by expectoration, suffer the bronchial secretions 
to accumulate, in the air passages. Hence the operation of an 
emetic, or spontaneous vomiting, by expelling the mucus from 
the bronchia, is always followed by an immediate, though but 
temporary cessation of the pectoral oppression and dyspnoea. In 
general, the more violent the cough is in the early stage of the 
disease, the less mucus is secreted and discharged from the lungs; 
and when the bronchial irritation is about passing into inflamma- 
tion, the cough, usually, becomes perfectly dry. In the ordinary 
form and course of the disease, the expectoration becomes very 
abundant, after the fever has continued for three or four days; 
and as the copious secretion of mucus keeps up a constant irri- 
tation of the bronchia, the cough, usually becomes very frequent 
as the disease advances. 

The liver, often, is much affected in this variety of fever. In 
infants, the epigastrium and right hypochondrium, sometimes, 
become tumid, tense and sore to pressure — a condition, which 



320 OF CATARRH. FEVER. 

has led to the vulgar notion that the child is " liver grown," as it 
is called. The liver, in cases of this kind, is evidently greatly 
engorged with blood, attended with more or less functional tor- 
por. During the first two or three days, the discharges from the 
bowels are frequently whitish or clay-colored; but as the dis- 
ease advances, an abundance of light-green or dark bile appears 
in the evacuations. In violent cases, delirium sometimes occurs, 
particularly in the afternoon and at night. There is generally a 
distinct remission of the febrile symptoms, in the morning, though 
usually of very short duration. 

The occurrence of bile in the evacuations, if accompanied with 
a soft and moist skin, and a more copious secretion of urine, is 
almost always followed by a speedy declension of the disease. 
When, on the contrary, the alvine discharges become watery 
and muddy, or reddish, with shreds and flocculi of mucus, resem- 
bling the washings of flesh, attended, as these discharges almost 
invariably are, by a bloated or tympanitic state of the abdomen, 
and a very dry and harsh condition of the skin, the worst conse- 
quences are to be apprehended. When death takes place, at an 
early period, it is generally from engorgement of the lungs and 
sudden effusion into the air cells, or from the supervention of 
bronchial or pneumonic inflammation. The occurrence of con- 
vulsions, in this complaint, is always a highly unfavorable circum- 
stance. Great somnolency or drowsiness, when attended with 
difficult breathing, is also very unfavorable, as they indicate 
strong cerebral and pulmonary congestions. 

During the declension of the disease, a very copious discharge 
of thick mucus generally occurs from the nose, and trachea; and 
this, with the cough, often continues for several weeks after the 
fever has completely subsided. 

Treatment. — In prescribing for this disease, we must endeavor 
to restore the regular action of the skin and liver; to moderate 
the febrile excitement of the heart and arteries; to allay the 
irritation of the mucous membrane of the respiratory passages, and 
to obviate local congestions or inflammations. The bowels should, 
in the first place, be freely evacuated, by a full dose of calomel, 
followed, in three or four hours, by a dose of castor oil, magnesia, 
or infusion of senna and manna. 



OF CATARRH. FEVER 321 

If the pulse is full and active, or when symptoms of severe pulmo- 
nary congestion or inflammation occur, blood ought to be drawn, 
so as to make an obvious impression on the circulation, either 
with the lancet or by leeching. When the child complains of 
pain in the chest, or when the breathing is laborious, this mea- 
sure is of great importance, and should never be neglected. In 
many cases, however, the pectoral symptoms are slight and the 
pulse is not sufficiently active to require or warrant the abstraction 
of blood. As soon as the bowels have been well evacuated, re- 
course should be had to antimonials, and to small doses of calo- 
mel in union with ipecacuanna, with a view of exciting the cuta- 
neous and hepatic secretions and keeping up a moderate action 
of the bowels. From a quarter to a half a grain of calomel, with 
a half a grain or a grain of ipecacuanna, according to the age of 
the patient, may be given three or four times daily, until the stools 
have become distinctly bilious. When this occurs, a dose of cas- 
tor-oil, or of magnesia should be administered, so as to procure 
pretty free purging. At the same time that this remedy is em- 
ployed, small doses of tartar emetic may be very beneficially ad- 
ministered. The best way, perhaps, of employing antimony in this 
disease, is to give it in combination with some mild expectorant mix- 
ture. I have found the following, very excellent mixtures for this 
purpose.* A teaspoonful may be given to an infant every two or three 
hours. After the febrile reaction has been moderated, or where 
it is feeble in the early stage of the complaint, much benefit will 
often result from the use of small doses of Dover's powder. Where 
however, the lungs are much oppressed, by too copious a secre- 
tion of bronchial mucus, and the patient appears drowsy, opiates 
are decidedly improper in infants; for, if the bronchial irritation 
is lulled by the use of opium, the cough will be suspended, and 
suffer the mucus to accumulate to a dangerous extent in the air cells 
and bronchia. When the breathing is oppressed from this cause 
in infants, nothing affords more certain and speedy relief than the 

* R. Muriate of ammonia, Qii; Extract. Glycyrrh. 3iii; Aq. fontarice, giii; Tart. 
Antimonii, grs. ii; Syrup. Scilte, 3iii. M. 

or 

R. Spirit. Minderiri, gii; Syrup. Scillae, gss; Vin. Antimonii, 3ii; Spirit. Nitri. 
Dulc. 3iii; Sarrh. AJbi g-. M 

■2 T 



322 OF CATARRH. FEVER, 

operation of an emetic. The concussive action of vomiting, rare- 
ly fails to free the lungs from the viscid mucus, that may be 
lodged in the bronchia and air cells. When the pectoral oppres- 
sion is severe, a large emolient poultice laid over the breast, will, 
frequently, procure considerable relief; but when the cough is 
violent and painful, and the breathing laborious, a blister applied 
to the chest will be the most effectual means of relief and ought 
not to be neglected. To promote the action of the cutaneous 
exhalents, the warm bath is sometimes very beneficial, particularly 
after the acute symptoms have, in some degree, subsided. During 
the declension of the disease, expectorants and small doses of opi- 
ate remedies, are usually of essential service. A mixture of equal 
parts of tinct. opii. camphoratas, syrup of squills, and sweet spirits 
of nitre, forms an excellent remedy for this purpose. From 
twenty to sixty drops, according to the age of the patient, should 
be given three or four times daily. The hive syrup, and brown 
mixture,* are also very useful expectorants, in the latter stage of 
the disease. 

Congestive Catarrhal Fever. — Infants are liable to a catarrhal 
affection, in which the prominent symptoms are those of violent 
pulmonary congestion, with but little or no development of febrile 
excitement. So far as I know, Dr. Parrish, of Philadelphia, is 
the first, who has given a particular account of this dangerous ma- 
lady, t This modification of the disease commences with cough, and 
the breathing soon becomes laborious and wheezing; the face is 
very pale, and the whole surface cold, though generally soft or 
moist. The pulse is considerably accelerated, but is free from 
tension, quickness, or firmness. The countenance acquires a 
peculiar expression of distress and anxiety, and in severe cases, the 
cheeks become very cold even when the other parts of the sur- 
face, are of a natural temperature. The stomach and bowels are 
generally inactive, and the urine is small in quantity, but so far 

* R. Extract, glyeyrrh. 3ii; Aq. fontanse %\v ■> Vin. Antimonii 3ii; Tinct. Opii. 
Camph. 3'i- M. Dose from one to two teaspoonfuls every three or four hours, accord- 
ing to the age of the child. 

t Observations on a peculiar Catarrhal Complaint in children. By Joseph Parrish, 
M. D. &e. — See, North American Medical and Surgical Journal, vol. i. p. 24. 



OF CATARRH. FEVER. 323 

as I have observed, nearly of a natural or healthy color. After 
the disease has continued for some time, a cold perspiration some- 
times breaks out on the face and neck. The cough is at first dry, 
attended with a wheezing sound in the chest; but towards the 
termination of the complaint, it frequently becomes humid 
or rattling. The pulse, in violent cases, becomes very small and 
rapid, and the tendency to sinking, is in all instances, very obvi- 
ous. There is constantly much difficulty of breathing, but at 
times, the oppression becomes so great as to resemble a violent 
attack of asthma. Occasionally considerable remissions occur, 
for a short period, during which the pulse will become somewhat 
fuller and slower, and the countenance brighter and more calm. 
When the disease is tending to a fatal termination, the patient 
becomes drowsy, insensible and comatose, and death takes place, 
by suffocation, or in a paroxysm of convulsions. 

This disease seldom continues longer than two or three days, 
and in very young infants, death sometimes takes place, in the 
course of the first day. It is most frequently met with in infants 
under a year old, and I have witnessed several cases during the first 
month. After dentition is completed, catarrhal affections appear 
to be less apt to assume this congestive character; although vio- 
lent pulmonary congestion and fatal effusion into the air passages, 
occur at every period of life as consequences of pneumonia or 
bronchial inflammation. 

Dr. Parrish thinks that the dyspnoea, which forms the promi- 
nent symptom of the disease, " is undoubtedly of a spasmodic 
character," depending probably on " a constitutional debility of 
the respiratory organs." My own observations have led me to a 
very different conclusion. From carefully attending to the phe- 
nomena and progress of several cases of this kind, 1 am entirely 
convinced, that the oppressed respiration and other characteristic 
symptoms of this disease, depend mainly if not wholly on great 
sanguineous engorgement of the pulmonary blood-vessels. The 
disease is manifestly catarrhal; but the lungs are, at once, so 
entirely oppressed by excessive sanguineous congestion, that the 
vital energies are too much depressed to admit of the develop- 
ment of distinct febrile reaction, and local inflammation. It 
seems to me to bear the same relation to acute bronchitis or 



324 OF CATARRH. FEVER. 

peripneumony, that apoplexy or coma does to phrenitis. It is a 
kind of apoplexy of the lungs. Extremely oppressed respiration, 
paleness of countenance, cough, and coolness of the surface, are 
precisely the phenomena we should expect to occur, from exces- 
sive sanguineous engorgement of the lungs. Dr. Parrish uses 
antispasmodics, particularly assafcetida and the oil of amber in 
the treatment of this malady; and he seems to regard their 
apparent usefulness, as an evidence of the correctness of his 
opinion on this subject — namely, that the "dyspnoea is undoubt- 
edly of a spasmodic character." It must be observed, however, 
that he employs, also, emetics, purgatives, blisters to the breast, 
and the warm bath; and although he regards them only as "use- 
ful auxiliaries" to the assafcetida and oil of amber, they are just 
such remedies, as one would place most reliance on for the removal 
of pulmonary congestion; and I cannot doubt that they were in 
reality the means which effected the beneficial results in the 
cases he has reported. 

Treatment. — The principal object in the treatment of this 
complaint, is to relieve the congested condition of the lungs, and 
to prevent the development of inflammation. The child should 
be immediately placed in a warm bath, and an antimonial emetic 
administered. Vomiting seldom fails to procure some benefit; 
but the relief obtained from it, is generally temporary, and in the 
beginning of the disease, sometimes but very slight. The most 
effectual means for relieving the lungs, is the application of a 
large epispastic over the breast, and this should never be omitted 
when the pectoral oppression is severe. The bowels, also should 
be freely evacuated; and for this purpose, a full dose of calomel 
is, perhaps, the most beneficial. Frequent and very active purg- 
ing, however, has appeared to me injurious in this complaint. 
After the intestines have, in the first place, been well evacuated, 
it will, I think, be best to keep them in a loose state, by the exhi- 
bition of a moderate dose of calomel in the evening, assisted 
if necessary, next morning, by a small portion of castor oil. To 
determine the circulation to the inferior parts of the body, some 
advantage may also be derived from the application of sinapisms 
to the feet. Dr. Parrish speaks very favorably of the use of assa- 



OF CATARRH. FEVER. 325 

foetida and the oil of amber. He mentions an extreme and an 
apparently hopeless case, the unexpected recovery of which he 
ascribes chiefly to the agency of the former of these antispasmo- 
dics. " I should," he says, " have despaired of the case, had I not 
known under what apparently hopeless circumstances infants 
sometimes recover. I ordered the warm bath, sinapisms to the 
feet, a large blister over the breast, and laxative injections con- 
taining assafoetida. But the remedy on which 1 chiefly relied, 
was assafoetida rubbed up with mint water, given frequently and 
in large doses. To the astonishment of every one who witnessed 
the case, my little patient perfectly recovered." The assafoetida, 
doubtless, had its share in the production of this fortunate result; 
but this case certainly cannot be regarded as a fair example of 
its efficacy, since the other means employed along with it, are 
by themselves, generally, sufficient to remove the disease. I 
have never yet employed any antispasmodics in the treatment of 
this affection — having always relied, principally, on the remedies 
already mentioned, particularly blistering, the warm bath, and 
emetics. When the pulse is very feeble, wine-whey, or a weak 
solution of the carbonate of ammonia may be used with much 
advantage. I would not, however, say any thing against the free 
employment of assafoetida; on the contrary, the authority of Dr. 
Parrish, is sufficient to convince me, that it is a remedy of excel- 
lent powers in this complaint. I doubt, however, whether its 
good effects can be justly ascribed to its antispasmodic operation. 
It is rather by a general stimulant and expectorant influence, I 
conceive, that it contributes to the reduction of this formidable 
malady. Dr. P. directs, that one drachm of this gum, be rubbed 
up with an ounce of mint-water, and given in teaspoonful doses, 
repeated every two hours. "If this shall be found too strong, it 
should be diluted, till of such a strength as the child can bear." 

I have as yet said nothing of blood-letting. When there is 
considerable fulness and activity in the pulse, the abstraction of 
a small quantity of blood, with the lancet, is often highly benefi- 
cial. I have, in some instances, procured prompt and very 
decided relief by bleeding. When the pulse is very frequent, 
small, and feeble, as it sometimes is, blood cannot be drawn 
without considerable risk of increasing the prostration to a fatal 



326 OF CATARRH. FEVER. 

extent. Before bleeding is resorted to, where the state of the 
pulse does not distinctly indicate the propriety of the measure, it 
will, in general, be best to premise the use of the warm bath, and 
the application of sinapisms to the feet. If these do not, in some 
degree, increase the fulness and force of the pulse, it will be 
most prudent to abstain from drawing blood. 

In moderate cases, I have known very obvious benefit to 
result from the application of a large emolient poultice, renewed 
every two or three hours, so as to keep it sufficiently warm and 
moist. 

When the bronchial exhalents begin to relieve themselves, by 
secreting an abundance of mucus; or when the respiration and 
cough are attended with a rattling sound in the chest, the hive 
syrup, or a decoction of the seneca root, repeated at short inter- 
vals, until vomiting is produced, will sometimes procure very 
considerable relief. Opiates are, in general, decidedly improper 
in this affection, particularly in very young infants, and when the 
secretion of bronchial mucus is copious. Dr. Parrish, says that 
the fumes of rosin "are often highly beneficial." I have my- 
self, in one instance, resorted to the inhalation of these fumes, 
with an evidently beneficial effect on the breathing. 



OF ACUTE BRONCHITIS. 327 



CHAPTER XXVI. 



ACUTE BRONCHITIS. 



This disease, as it occurs in infants, often bears a close resem- 
blance, in its early stage, to the congestive complaint described 
in the preceding section. They are, indeed, produced by the 
same cause; but in the present disease along with the sanguine- 
ous engorgement of the lungs, more or less inflammation, is 
developed in the mucous membrane of the bronchia. 

The disease usually begins, with chilliness, or a cold and con- 
tracted state of the surface, a languid and pale appearance 
of the countenance, slight cough, and some difficulty of 
breathing. After some time, the pulse becomes frequent, quick 
somewhat full and resisting. The cough increases, is slightly 
hoarse, and has a stifled sound. The breathing also, rapidly 
becomes more and more oppressed and laborious. When the 
child is old enough to give an account of its sensations, it com- 
plains of a feeling of weight and tightness in the breast, but 
seldom of any pain. Nevertheless, when the cough is violent, 
infants sometimes cry out, as if from pain; and the inspirations 
are occasionally catching and attended with an expression of 
pain in the countenance. At first the breathing and cough are 
dry, but in the course of the first twelve hours, and often soon 
after the commencement of the febrile reaction, a copious secre- 
tion of transparent, viscid mucus takes place, into the bronchia. 
In most instances, vomiting occurs during the first twenty-four 
hours; and the epigastrium frequently becomes distended and 
elastic. As the disease advances, the mucous secretion into the 
air cells and bronchia, increases progressively; the child becomes 
drowsy, the lips livid, and the countenance expressive of great 
distress, the muscular debility is always very great. When the 



328 OF ACUTE BRONCHITIS. 

disease is once fully developed, the child often manifests much 
uneasiness by being placed in the recumbent position. The 
countenance is very rarely, even slightly, flushed; on the con- 
trary, throughout the whole disease, it is almost invariably 
extremely pale and anxious. Towards the fatal termination, the 
cheeks and lips sometimes acquire a slightly livid hue. The 
temperature of this surface, is generally somewhat above the 
natural standard, on the trunk, — but the hands and feet, are fre- 
quently cool or about the regular temperature. The difficulty 
of respiration, is not uniform. Occasionally it is pretty easy, for 
a short period, and then suddenly, becomes, extremely oppressed. 
The cough too, after the disease has continued, until the secre- 
tion of bronchial mucus is very copious, becomes, in a manner, 
paroxysmal — violent spells coming on at irregular, and generally 
short periods, with comparative exemption from it, during the 
intervals. 

The progress of the disease, is generally rapid. In some in- 
stances it terminates fatally as early as the third day; more 
frequently, however, its course is protracted to the sixth daj\ 
Great drowsiness or coma, almost invariably precedes the fatal 
termination. But even after the lungs appear to be completely 
clogged with the effused mucus, and the child has sunk into a 
comatose state, " gleams of hope sometimes burst upon us. For 
a short time the difficulty of respiration may seem to subside, and 
the child to be better. But these hopes are very rarely realized; 
for even the next exacerbation of dyspnoea may terminate in 
suffocation." 

On dissection the lungs do not collapse when the thorax is 
opened. The whole structure of the lungs, usually appears, 
infiltrated, or engorged with a thin viscid fluid. The mucous 
membrane of the bronchia, is generally of a bright red color, 
from minute injection of its capillary vessels. The smaller 
branches of the bronchia, are commonly filled with tough mucus, 
bloody serum, or purulent matter. In those cases that succeed 
pustular exanthematous affections, the mucous membrane of the 
large bronchial tubes, sometimes presents a number of very small 
ulcerations, and slight fungoid elevations. In severe cases, it is 
not uncommon to meet with a red hepatized condition, of a 



OF ACUTE BRONCHITIS. 329 

portion of the lungs; and occasionally there is an approach 
towards the formation of tubercles. 

The great muscular prostration and somnolent condition which 
occur in this disease, doubtless, arise from deficient decarboni- 
zation of the blood; for death generally occurs from asphyxia, 
or suffocation, in consequence of the entire obstruction of the air 
cells, and smaller bronchial branches, by the viscid mucus so co- 
piously secreted in this affection. It seems probable, however 
that death sometimes occurs, also in consequence of the inflamed 
mucous membrane preventing the atmospheric air from producing 
the necessary change in the veinous blood. Cases of fatal dysp- 
noea are related by M. Andral, jr. in which no effusion or redundant 
secretion of mucus had taken place, nor any lesion of the proper 
substance of the lungs, discovered on dissection. It seems highly 
probable, that, whether the oxygen enter into the blood-vessels, or 
the carbon be thrown out through the mucous membrane, the regu- 
lar influence of the air, on the veinous blood, will be impeded or 
perverted when this delicate structure is in a state of intense 
inflammation. The difficulty of respiration which occurs in the 
early stage of this complaint, is, perhaps, chiefly attributable to 
this cause, and not to the clogging of the bronchial cells, by vis- 
cid secretions, as is generally supposed. 

Treatment. — Blood-letting is in general a highly valuable means 
of relief, in the early stage of this affection. In robust and ple- 
thoric infants, particularly when the pulse is active, prompt and 
efficient, bleeding, either with the lancet or by leeching, may be 
deemed indispensable. The period, however, during which this 
measure may be resorted to with a prospect of advantage is not 
very long. The blood ought to be abstracted at an early period 
— as soon after the inflammation is developed, as possible. If it 
be delayed, until effusion or a copious secretion of bronchial mucus 
has taken place, the chance of benefit from it, will be but very 
small, and injury, probably, will be the result. If the cough is 
dry, and the respiration not attended with a rattling sound in the 
trachea, blood may be drawn, with a fair prospect of advantage; 
and a sufficient quantity ought to be taken away, at the first bleed- 
ing, to make an obvious impression on the action of the heart and 

2U 



330 OF ACUTE BRONCHITIS. 

arteries. Much benefit may be derived from the application of 
leeches to the chest; more especially, after blood has been ab- 
stracted with the lancet. No remedy, however, contributes 
more powerfully to the reduction of the bronchial inflammation 
than blistering. As soon as blood has been efficiently abstracted 
or at once in the very commencement of the disease if the pulse 
be small and feeble, a large epispastic ought to be laid over the 
breast and suffered to remain until the skin is uniformly inflamed. 
It must then be removed and a large emolient poultice laid over 
the part. 

The bowels should be freely evacuated, by a full dose of calomel 
and rhubarb; and afterwards kept in a loose state by purgative 
enemata, and small doses of some of the milder laxatives. Half 
a grain of calomel with the same quantity of ipecacuanna may be 
advantageously used for this purpose. Emetics also are very use- 
ful remedies, in this affection. They generally procure immediate 
relief of the oppression in the chest, by expelling the viscid mucus 
which clogs the bronchial cells, and diminishing the pulmonary 
congestion. A mixture of antimonial wine and syrup of squills, 
in the proportion of one part of the former to three parts of the 
latter, forms an excellent emetic, for this purpose. A teaspoon- 
ful of this mixture should be given every twenty minutes, until 
active vomiting is excited. Expectorants may also be used with 
advantage in this affection. In the early period of the disease, 
the more stimulating articles of this kind must be avoided. I have 
frequently employed the following mixture, for this purpose, with 
evident benefit.* After the febrile reaction has been moderated 
and there is much secretion into the bronchia, the more stimula- 
ting expectorants, will be proper. The following combination, 
frequently, produces a very good effect, in the advanced periods 
of the disease.! When there is much prostration, or when the 
pulse is small and feeble, in the latter stage of the disease, stim- 
ulants should be used, along with expectorants. The carbonate 
of ammonia is an excellent remedy in this state of the disease. It 

* R. Tart, antimonii. gr. ii ; sal. tart. 3 U > aq. fontanse giiss mel. opt. giss. M. 
Dose, a tea spoonful every hour or two. 

t R. G. ammonias gii; infusio polygala senegae giv; syrup scillae gss. Dose, a tes- 
spoonful, every two hours. 



OF ACUTE BRONCHITIS. 331 

may be given according to this formula.* Hoffman declares, that 
he has known a combination of the flowers of benzoin and cam- 
phor, to procure complete relief, in cases, apparently hopeless. 
To an infant, of from one to three years old, a quarter of a grain 
of the former article with half a grain of the latter, rubbed up 
with a small portion of sugar, may be given every two hours. 

Opium is seldom beneficial in this disease; and may readily do 
a great deal of harm, by suspending, for a time, the efforts to ex- 
pectorate, and thus giving rise to a dangerous accumulation of 
mucus in the bronchial tubes. When the cough remains dry, 
(which however, is rarely the case) and the momentum of the cir- 
culation has been diminished by depletion, considerable benefit 
may be derived from the judicious employment of this narcotic. 
In such cases, small doses of Dover's powder, in union with calomel, 
generally moderate the violence of the cough, and assist expecto- 
ration. To allay general irritation, and restlessness, during the 
declension of the disease, the tincture of hyoscyamus or of bella- 
donna is often very useful. Exhibited in doses of from two to 
four drops every four hours, it seldom fails to tranquillize the ner- 
vous system, and to moderate the cough. When the skin is slow 
in resuming its regular perspiratory action, these narcotic tinctures 
may be very beneficially given in union with antimonial wine. 

* R. Carbon, ammon. 9ii; ext. glycyrrh. 3" j aq. fontanse, giv, acid, scillae 3"- 
M. Dose, a tea spoonful every hour or two. 



332 OF PLEURITIS. 



CHAPTER XXVII 



PLEURITIS. 

Inflammation of the pleura is a much more common affection, 
during infancy than many suppose.* It commences as other in- 
flammatory affections do, with a feeling of chilliness and a pale 
and contracted state of the surface. This is soon succeeded by 
high febrile reaction. The skin becomes very dry and warm, the 
face flushed, and the pulse frequent, full and strong. The breath- 
ing is hurried, short and somewhat oppressed, particularly when 
the patient is lying down. The cough is at first dry and short, 
and the infant evidently endeavours to stifle it as much as possible, 
to avoid the pain which it always occasions. When the child is 
laid down, it generally begins to cough and cry, and the muscles 
of its countenance are contracted into an expression of pain and 
suffering. There is also much more cough and uneasiness, when 
the patient lies on one side than on the other. In some instances, 
the patient rests easiest when lying on his back, with the head 
and shoulders raised, both sides being equally affected. Some- 
times each inspiration is attended with a whine or moan, and the 
countenance is always expressive of pain. If the disease is not 
early moderated, or checked in its course, the breathing becomes 
more and more difficult and painful; and if any of the viscid bron- 
chial mucus is thrown out, it is frequently found streaked with 
blood. "The cough is attended with a rattling sound in the 
trachea; the extremities become cold; the countenance often 
slightly livid, and the patient finally sinks into a state of drowsi- 
ness or stupor. The pulse, at last, becomes irregular, and often 
intermittent, the extremities swell, the breathing becomes short, 
and a frothy fluid oozes from the mouth." During the whole 
course of the disease the respiration is performed, chiefly by the 

* Dr. Burns. 



OF PLEURITIS. 333 

action of the abdominal muscles, and diaphragm — the motion of 
the chest being instinctively restrained by the patient, on account 
of the increase of pain which the dilatation of the thorax or eleva- 
tion of the ribs always occasion in the inflamed pleura. 

On post mortem examination, the pleura is generally found uni- 
formly red, or punctuated with an infinitude of red specks of 
irregular shape, and very close together. In many cases a con- 
siderable quantity of serum is effused into the cavity of the pleura ; 
and adhesions, more or less extensive, between the costal and pul- 
monary pleura occur in the majority of instances. Occasionally, 
some portions of the lungs are found hepatized ; and a general 
infiltration of serum into the pulmonary structure is not un- 
common. 

The occurrence of diarrhoea in this disease, is always an ex- 
tremely unfavorable circumstance; convulsions and coma, too, are 
no less ominous of a fatal tendency. Great distress and agitation, 
when placed in recumbent position, particularly when the breath- 
ing is attended with a wheezing sound in the trachea, and the 
pulse is small and irregular are extremely unfavorable signs. 

When the skin becomes uniformly moist, the pulse less frequent 
and soft, the cough attended with a free discharge or raising of 
bronchial mucus, and the patient is able to rest on either side, a 
favorable termination may be confidently expected. 

Treatment. — Prompt and very efficient blood-letting is indispen- 
sable in the treatment of this form of pectoral inflammation. 
Blood should be freely drawn with the lancet, until a decided im- 
pression is made on the pulse. The early application of leeches 
to the chest is also a highly important measure. As soon as the 
momentum of the circulation has been moderated, a blister ought 
to be laid over the breast, and managed in the way mentioned in 
the preceding chapter. The bowels must in the first place be 
freely evacuated, by an efficient dose of calomel and rhubarb, and 
kept in a loose state throughout the whole course of the disease, 
by small doses of calomel and ipecacuanna, or suitable portions of 
epsom salts. 

The cooling diaphoretics are very useful auxiliary remedies in 
this affection. The nitrate of potash with minute portions of an- 



334 OF PLEURITIS. 

timony generally contributes materially to the reduction of the fe- 
brile irritation. The following is an excellent mixture for this 
purpose.* Small doses of the pulvis antimonialis, in union with 
calomel, may also be employed, with much advantage, when the 
skin is very dry and warm. With the view both of diminishing 
the action of the heart and arteries, and of promoting expectora- 
tion, a simple solution of tartar emetic, given in very small but 
frequent doses, often proves decidedly beneficial. Dr. Burns says, 
that antimonials ought never to be given, in this complaint, to the 
extent of producing "decided sickness." I have witnessed no 
evil consequences from nauseating doses of tart, emetic, in the 
present disease, but, on the contrary, often unequivocal bene- 
fit. I have generally made it a point to administer this arti- 
cle so as to produce slight manifestations of nausea; and I am 
persuaded, that in the early stage of the disease, while the pulse 
is active and the skin hot and dry, much advantage will in 
general, result, from this mode of employing antimony. As a dia- 
phoretic expectorant, the kermes mineral, given according to 
the formula below,t sometimes produce a very good effect, parti- 
cularly when the cough is dry and harsh. If after the disease has 
been in a great degree subdued, the cough continues to be very 
severe, and the patient is restless, considerable benefit may some- 
times be obtained from the use of small doses of Dover's powder. 
A few grains administered, once or twice daily, usually has the 
effect, of improving the expectoration, allaying the pain and rest- 
lessness, and exciting the regular action of the cutaneous ex- 
halents. This article is particularly useful, during convalescence 
from this and other forms of pectoral inflammation, more espe- 
cially when the pulse is small, and irritated and the skin dry. 
In the advanced stages of the disease, when (although the local 
inflammation and fever, appear to be almost entirely subdued,) the 
child is incapable of resting in a recumbent posture, the employ- 
ment of diuretic remedies is sometimes attended with marked 

* Nitrat. potassze, gii; extract, glycyrrh. 311; tart, antiraonii gr. ii; sacch. albi. 
gss; aq. fontanae giii. M. Dose, one or two teaspoonfuls, every hour or two, according 
to the age of the patient. 

t Kermes mineralis gr. xv ; extract, glycyrrh. 3ii ; aq. fontanae giii. ; syrup Scillse 
3ii. M. Dose, a teaspoonful every two or three hours. 



OF PLEURITIS. 335 

benefit. In cases of this kind there is often a considerable quan- 
tity of serum effused into the cavity of the pleura, so that the mo- 
ment the child is laid down, with its head low, it becomes agitated 
and begins to cough, pant, and cry. To promote the absorption 
of the effused fluid, small doses of squill and calomel, ought to be 
given three or four times daily, until the child is able to sleep in 
a horizontal position. The fourth of a grain of dried squills with 
the same quantity of calomel forms a full dose for a child, of from 
one to three years old. A mixture of the tincture of digitalis and 
vinegar of squills, in equal quantities, may also be used for this 
purpose; and I have known much benefit to result in this respect, 
from a mixture of equal portions of the syrup of squills and the 
sweet spirits of nitre, given in doses of from twenty to thirty drops, 
three or four times in the course of a day. When after the pleu- 
ritic symptoms have been removed, the child continues to be 
affected with cough, and a short and uneasy respiration, no reme- 
dy has appeared to me so valuable as the tincture of sanguinaria 
Canadensis. I have rarely known it to fail in removing the pul- 
monary irritation in such cases. From two to four drops may be 
given three times daily to a child under three years old. 



336 OF PAROTITIS. MUMPS. 



CHAPTER XXVIII. 



PAROTITIS. MUMPS. 



Parotitis is a specific inflammatory affection, particularly 
liable to be transferred to the testes in males and mammas in 
females; propagated by a peculiar contagion, and occurring 
sometimes spasmodically. 

Symptoms. — Slight febrile symptoms generally usher in the 
disease, which is first manifested by a feeling of stiffness about 
jaws, and a little tumor and pain in one or both parotid glands. 
The swelling in the beginning is moveable, but it soon becomes 
widely diffused, frequently involving the maxillary glands. It 
gradually increases until the fourth day, when the affected gland 
is very firm, tender and elastic to the touch. The skin over the 
tumor retains for the most part its natural hue, although in some 
instances it is changed to a pale red, and occasionally a bright 
red color. The maxillary glands, are sometimes more largely 
affected than the parotid. Mastication and deglutition are in all 
cases attended with considerable pain. The fever is in general 
mild, though the patient is frequently troubled with considerable 
restlessness and nervous irritability. The inflammation begins to 
decline about the fourth day, and very rarely tends to suppura- 
tion. The other inflammatory symptoms now likewise subside, 
and about the seventh day from the beginning of the disease, 
detumescence is complete. Diaphoresis, more or less general, 
and a red urinary deposition, usually accompany the subsidence 
of the affection. 

Metastasis of the disease sometimes occurs upon the decline of 
the inflammatory symptoms. In females, the breasts, and in 
males, the testicles are apt to become hard, swollen and more or 
less painful to the touch. This symptom, according to some 
respectable writers, is rather favorable than otherwise; for some- 
times where it has been absent, an exacerbation of the sympto- 



OF MUMPS. 337 

matic fever has taken place, violent cerebral disturbance ensued, 
and death been the result. Dr. Hamilton relates several instan- 
ces, in which, after considerable enlargement of the testicles, 
occurring upon the decline of the disease, this organ wasted 
entirely away, so that the tunica vaginialis became an empty sack. 
Improper exposure to cold, will sometimes cause a sudden transi- 
tion of the affection to these parts, in which case, if the treat- 
ment be not judicious, suppuration may ensue — a very painful 
event and one that may terminate fatally. The same cause 
sometimes occasions a metastasis of the inflammation to the hrain. 
Coma, or furious delirium now generally supervenes, and death 
usually follows in the course of a few hours. A case of this 
kind came under my notice, where in less than an hour, the 
patient expired in a paroxysm of convulsions. We must not 
forget that a metastasis of the disease to the mammas or testes 
is no absolute security against a secondary translation of it to 
the brain.* 

Children and young persons are most liable to the attacks of 
this complaint, its appearance in maturer life being very uncom- 
mon. It rarely affects the same individual more than once, resem- 
bling thus the other acute contagious diseases. Parotitis, occurring 
in advanced life, shows an aptitude at times to take on a chronic 
form, accompanied by very serious symptoms. This aptitude is 
most apt to occur in females in whom the menses are about 
ceasing, and whose general systems are in some measure deranged. 
Although suppuration is an uncommon termination in this com- 
plaint, it may yet under circumstances favoring it, take place. 

With the exception just noted, Parotitis may be said to be nei- 
ther a severe nor dangerous affection — particularly where the 
patient avoids exposure to low or variable temperature, and keeps 
the affected parts moderately and uniformly warm. 

Treatment. — In mild cases, beside attending to the precau- 
tions just mentioned, little more is necessary than keeping the 
bowels open and using gentle diaphoretics. Sometimes the in- 
flammatory symptoms run high, and we should then resort to 

* See history of an Endemic Parotitis, &c. Edinburgh Med. and Surg. Journ. Vol. 4, 
p. 304. 

2X 



338 OF MUMPS. 

active antiphlogistic measures. When the swelling disappears in 
the neck and shows itself in the testicles, blisters should be applied 
to the parotids, and every effort made to excite a general diapho- 
resis. A mild, cooling regimen is to be enjoined, and where the 
pain is extreme and the symptomatic fever severe, we must have 
recourse to full purging and sometimes to venesection. Emetics 
have occasionally been productive of much benefit in such cases. 
To discuss the hard tumefaction not unfrequently remaining after 
the disappearance of the inflammatory symptoms, frictions with 
mercurial ointment, spirits of camphor or rubefacient liniments 
should be used. 



Quinsy. 339 



CHAPTER XXIX. 



TONSILLITIS. CYNANCHE TONSILLARIS. QUINSY. 



Inflammation of the tonsils and fauces, is a frequent complaint 
among children. It generally commences with a feeling of 
chilliness, accompanied with a huskiness of voice, an uneasy sen- 
sation in the fauces, and a stinging or cutting pain, in this part, 
on swallowing. More or less febrile reaction ensues; and in a 
few hours a fixed pain is experienced in the region of the tonsils, 
and the swallowing becomes more and more painful, until at last 
the action is productive of extreme anguish. On examination, 
one or both tonsils are found swollen, and the whole surface 
of the fauces present a tumid and florid aspect. In some instan- 
ces, the uvula and soft palate, exhibit a highly cedematous and 
dark red appearance. The tongue is covered with a white fur, 
through which the florid and enlarged papillae project; and over 
the whole, a thick layer of tough transparent slime is spread. 
In severe cases, the face becomes flushed and tumid; the carotids 
beat strongly; respiration is laborious, hearing obtuse, the pulse 
frequent, full, and hard, and the voice indistinct or whispering. 
In general, the patient swallows soft or pultaceous substances 
with more ease and less suffering, than liquids. Severe pains, 
usually dart from the fauces into the ears, — particularly when 
the patient attempts to speak or to swallow; and the mouth is 
opened with great difficulty and pain. The breathing is much 
obstructed by the extremely viscid mucus, which is so copiously 
secreted in the fauces; but in violent cases, the principal and 
most alarming source of difficult respiration is the enlargement 
of the tonsils; for when both are inflamed, they sometimes 



340 QUINSY. 

become so much swollen, as to come in contact wtth each other, 
confining the uvula behind them, or pressing it forward into the 
mouth. 

In some instances flakes of coagulable lymph of a whitish 
color adhere to the inflamed tonsils, resembling superficial 
sloughs. In cases of this kind, the inflammation is always of a 
vivid red color, and its tendency is either to resolution or suppura- 
tion. Occasionally, however, the inflammation assumes more of an 
erysipelatous character, the affected parts exhibiting a dark livid, 
and cedematous appearance, with small aphthous ulcers of white 
or grey color on the tonsils and uvula. Instances of this kind, 
very rarely terminate in suppuration. 

Inflammation in this disease terminates in resolution or suppur- 
ation, — gangrene hardly ever occurring, although at times a few 
sloughy spots are visible in the fauces. In no structure is abscess 
more frequently the result of inflammatory action, than in the 
tonsils. Internal suppuration will often take place in a few days, 
despite of the most active local and general antiphlogistic mea- 
sures. The quantity of matter formed in a suppurated tonsil is 
seldom abundant: it is not often very perceptible in the sputa, a 
portion of it undoubtedly being commonly swallowed with the 
saliva. Occasionally the abscess has pointed and broken out- 
wardly, under the angle of the jaw. Dodonasus relates a case, in 
which the patient appeared near death, where prompt relief was 
procured by an external incision in the abscess, and the conse- 
quent discharge of a large quantity of pus. 

This disease is never contagious, and though for the most part 
violent in its character, it is of short duration. In some instances, 
the inflammation passes down into the larynx, an occurrence that 
always increases the risk from the affection. Where this disease 
occurs in the same individual more than once, a predisposition to 
it is apt to be established. Frequent attacks tend also to occasion 
permanent enlargement and induration of the tonsils. In cold 
and variable climates, it is a complaint of frequent occurrence; 
and although by no means so dangerous as anginose affections of 
the respiratory passages, it is much more painful, in violent cases 
always alarming, and sometimes fatal. The young and the san- 
guine are said to be particularly liable to its attacks. 



QUINSY. 341 

Some individuals are peculiarly predisposed to this disease. 
This, as before observed, is especially the case with persons, 
who have suffered once or twice from its invasion. But other 
causes such as the constitutional influence of mercury, salivation 
and a strumous habit of body, appear to create or constitute a 
predisposition to the complaint. 

Cold and damp air, or cold applied in any manner, so as to give 
a sudden check to the perspiration, is the ordinary exciting cause; 
and hence the frequency of its occurrence in spring and autumn, 
when vicissitudes and variable temperatures are most common. 
Standing or sitting long on cold and damp ground is particularly 
apt to give rise to the, complaint, in those who are predispo- 
sed to it. 

Treatment. — The treatment of this affection must, of course, 
be strictly antiphlogistic; and, it is of much importance that effi- 
cient means be employed as soon as the disease is noticed ; for, 
even where the onset of the disease is mild, we have no security 
that its course will not be marked with extreme violence. When 
the pulse is full and active, blood ought to be promptly and effi- 
ciently drawn. In children, however, the febrile reaction is not 
often so vehement in the commencement of the disease, as to 
require a copious abstraction of blood; and in mild cases the 
inflammation may often be speedily subdued, with counter-irrita- 
ting applications, purgatives, warm pediluvium, &c, without the 
aid of direct depletion. Nevertheless, blood-letting, when regu- 
lated according to the state of the pulse, is always a safe and 
useful measure, and should never be omitted when the symptoms 
do not readily yield to other appropriate means. 

Purgatives are highly beneficial remedies in this affection. An 
active purge should be administered in the commencement of 
the treatment, and, repeated daily, until the inflammation is sub- 
dued, or has terminated in suppuration. For this purpose we 
may use five or six grains of calomel, followed in an hour or two 
by a suitable dose of epsom salts. I have known prompt and 
decided relief obtained from the use of the following emeto- 
cathartic mixture, given in doses of from a dessert to a table 
spoonful every hour, according to the age of the patient, until 



842 QUINSY. 

vomiting and purging was produced.* Diaphoretics, also, are 
useful auxiliaries, in the treatment of this affection. Nitre, in 
union with antimony, forms an excellent remedy for this purpose. 
Some advantage may he gained by causing the patient to place 
the nitre on his tongue, and swallow it as it is gradually dis- 
solved in the mouth. Much benefit may in general be derived 
from nauseating doses of tartar emetic. Of two ounces of water, 
holding a grain of tart, antim. in solution, a teaspoonful is to be 
taken every thirty minutes, so as to keep up a considerable 
degree of nausea for several hours. I have frequently prescri- 
bed the medicine in this way with the happiest results. The 
muriate of ammonia, dissolved in water, with the extract of 
liquorice, has been particularly recommended, t 

Emetics were once a good deal employed in tonsillitis, but their 
effects are much less beneficial in this, than in any of the other 
anginose affections. In infants, however, they are often highly 
beneficial, by removing the extremely viscid mucus which ad- 
heres to the palate, tonsils and fauces, and obstructs respiration. 

Topical bleeding, by scarifying the tonsils, generally produces 
excellent effects. Kopp thinks, that blood drawn in this way 
from the tonsils, is the most certain, prompt and efficacious reme- 
dial measure we possess. The early application of leeches to 
the throat or under the ear, although of less value, perhaps, than 
scarification, should by no means be neglected. Cupping on the 
back of the neck and under the ears, may, also, be resorted to 
with advantage. 

So soon as the momentum of the circulation has been reduced 
by venesection, a blister should be applied to the throat, or on 
the back of the neck. In slight cases of the disease, rubefacients, 
particularly the spirits of turpentine, or a liniment composed of 
two parts of aq. ammonias to one of sweet oil, will in general 
suffice. Emollient poultices are also very useful applications in 
mild cases. Employed in the commencement of the disease, 
together with warm pediluvium and a purgative, the further pro- 
gress of the inflammation, will sometimes be speedily and effectn- 

* R Sulph. magnesia;, gss. 

Aq. fontanEe, gviii. 

Tart, antimonii, gr. i. 

i Leoffler. Bcitacgen Zur Arzn. Wissensch. 1. Th. Leips. 1791, p. 142. 



QUINSY. 343 

ally arrested. Three or four folds of thick flannel round the 
neck, in such instances, with the auxiliaries just mentioned, are 
often sufficient to prevent the developement of the malady. But 
in every case where inflammation is considerable, immediate 
recourse must be had to vesication. 

The early use of astringent and acid gargles has been much 
recommended. Cullen advises a decoction of oak bark, with 
alum dissolved in it, as a useful prescription for this purpose. 
For myself, I generally prefer simple warm water, acidulated 
with vinegar. The principal advantage of gargles in this com- 
plaint would seem to be that of dissolving and removing the 
viscid mucus, adherent to the tonsils and palate; and this is best 
accomplished by warm water, either alone, or with a portion of 
some vegetable acid, and perhaps honey. Pringle says, that he 
never derived any benefit from astringent gargles, and accord- 
ing to Storch, they have at times been evidently injurious, by 
checking the exhalation and secretion from the mucous surface 
of the inflamed parts. 

The inhalation of certain vapors by any simple machine, is one 
of the oldest remedies in this affection. The vapor of vinegar 
and water was used by Hippocrates. 

If it is obvious that suppuration cannot be prevented, every 
proper measure should be taken to facilitate this termination. 
The steam of warm water, or of water impregnated with rose- 
mary or chamomile leaves, should be inhaled, and astringent 
gargles should at once be discontinued. When the fluctuation 
and other symptoms indicate the formation of a tonsillar abscess, 
it should by all means be immediately pierced with a lancet; as 
the discharge of the matter will always give instant relief from 
the pain and difficulty of respiration. After the operation, the 
patient should continue for a little while, the use of some mild 
and slightly acidulated or astringent gargle. 

Occasionally, from the extent and violence of the inflamma- 
tion in tonsillitis, there has been so much danger of suffocation, 
that it has been found necessary to make an opening into the 
trachea; which has been done sometimes as high as the larynx, 
and sometimes considerably lower; and under both kinds of 
operation the patient has recovered. (Good.) 



344 croup, 



CHAPTER XXX. 



CYNANCHE TRACHEALIS. TRACHEITIS. CROUP. 

Cynanche trachealis may be defined: an inflammation in the 
glottis, larynx and upper part of the trachea, attended with a 
hoarse and ringing cough, sonorous respiration, and a sense of 
impending suffocation. 

This form of cynanche does not appear to have been generally 
known as a distinct disease, until Home described it in a work 
published at Edinburg in 1765. It is not at all likely, however? 
that the disease is one of modern date, since its ordinary causes 
have always existed, and it cannot be presumed, that at any 
period of the world, their influence could have been materially 
different from what it is at the present day. The disease was 
confounded, no doubt, with other anginose affections, to some of 
which it bears, indeed, a very close resemblance in many of its 
prominent phenomena. 

In the long list of human diseases, there is none which presents 
a more painful scene of anguish and distress, or which excites 
more poignant feelings of sympathy in the heart of the physician, 
than the one now under consideration. I have witnessed the ap- 
proach of death under a multitude of appalling forms; but in all 
the death-bed scenes which it has been my misfortune to witness, 
I have never had my feelings so deeply afflicted as when looking 
on a blooming child struggling under the ruthless grasp of this 
terrible disease. In some instances this disease comes on sud- 
denly, and in a very short time acquires the utmost degree of vio- 
lence. More frequently, however, it is gradually developed — a 
dry and hoarse cough, attended with slight difficulty of breathing, 
roughness of voice, and some degree of languor or lassitude, being 
the first intimations of its approach. These symptoms sometimes 
continue for several days, before the disease is fully developed. 



croup. 345 

Sooner or later, however, the breathing becomes more difficult, 
the febrile irritation more obvious, the voice more indistinct and 
whispering, and the cough more hoarse and sonorous. There is 
something so peculiar in this hoarsness — such a rough, ringing, 
and dry sound in the cough, as can never be mistaken by those 
who have once heard it— and whoever has once heard it in con- 
nection with the distressing symptoms which characterize the dis- 
ease in its state of full development, can never hear this croupy 
cough, without the most anxious apprehensions. The disease 
now advances rapidly, and in a short time, acquires the most 
alarming and distressing degree of violence. The countenance 
is flushed; the ej r es prominent, injected and heavy; the pulse fre- 
quent, tense, and quick; the skin dry and hot; and the respira- 
tion extremely laborious and anxious. In the commencement of 
the disease the cough is often quite dry; but in the majority of 
cases, a very viscid and thick mucus is secreted by the mucous 
membrane of the fauces and larynx from its very on-set, and 
which from its spissidity contributes greatly to increase the diffi- 
culty of breathing. The sound attending the respiration, espe- 
cially the act of inspiration, is at first ringing and rather clear; 
but in the advanced period of the disease, it is characterized by 
a peculiar wheezing, as if the air were forcibly driven through a 
very narrow aperture. The act of inspiration is always performed 
with much more difficulty, and occupies a much longer time than 
the expiration of the air. This latter act is, comparatively, 
quick and always unaccompanied with the shrill and wheezing 
sound which attends inspiration. In the advanced periods of the 
disease, the cough is in all instances attended with a rattling 
sound, and the expulsion of extremely tenacious mucus from the 
trachea. 

If the progress of the disease be not checked, the difficulty of 
breathing increases progressively, until, at last, the oppression be- 
comes inexpressibly distressing. The countenance and motions 
of the little patient indicate the utmost degree of anguish and suf- 
fering. The head is thrown backwards, and the mouth kept 
open to facilitate respiration; the face is of a pale livid hue, the 
eyes are prominent and half closed; the lips purple, the muscles 
of the face agitated with the respiratory effort; large drops of sweat 

2 Y " 



346 CROUP. 

hang on the temples and upper lip; the extremities become cold and 
clammy; partial insensibility ensues; the breathing becomes fee- 
ble and interrupted, and the patient finally sinks into a state of 
total insensibility, which soon puts a termination to the agonizing 
struggle. 

Such are the ordinary course and symptoms of this dangerous 
affection. Much diversity, however, occurs, in relation to the 
degree of violence and rapidity of these phenomena. In some 
instances, the disease proceeds very slowly, the child being trou- 
bled during the day with some difficulty of breathing and a hoarse 
and dry cough, while at night an alarming paroxysm of croup will 
occur, and continue until towards morning. In this way, the 
disease will sometimes go on for five or six days; the patient being 
so free from any difficulty of breathing during the day, as to induce 
a belief that the disease has been subdued. At night, however, 
another attack will, perhaps, occur, and continue, with unceasing 
violence, and in opposition, often, to all our remedial efforts, until 
it terminates in death. Occasionally the disease is very gradu- 
ally developed, and continued for nine or ten days, without at any 
time acquiring a very alarming degree of violence. In cases of 
this kind the patient is harassed with a very hoarse cough, and 
considerable difficulty of breathing, with occasional severe ex- 
acerbations of the croupy symptoms, both during the day and at 
night. There is generally a* pretty copious secretion of mucus in 
the trachea in such cases, and the respiration is usually con- 
stantly attended with a rattling sound in the chest. These pro- 
tracted and remitting cases of croup are most apt to occur during 
difficult dentition. 

It would seem, that in some instances, the predisposition to 
this disease is congenital; for it is well known, that the children 
of some families are peculiarly predisposed to this complaint, 
whilst in other families, it never makes its appearance. It is 
manifest, also, that there is something peculiar to infancy and 
childhood, which increases the liability to this affection; for its 
occurrence is vastly more common between the first and fifth 
year of age, than in the whole subsequent period of life. This 
aptitude to the disease during early childhood, has been ascribed 
to the peculiar condition of the glottis and larynx, at this age; 



CROUP. 347 

for the existence of some peculiarity in this portion of the respi- 
ratory passages during infancy and childhood, unconnected, pro- 
bably, with mere size of aperture, may be inferred from the cha- 
racteristic voice at this early period, and its remarkable change 
at the age of puberty. There is another circumstance, how- 
ever, which may have a share in creating the aptitude in ques- 
tion, and which has reference to the exciting cause of the disease. 
The almost univeral mode of clothing infants — with their necks 
and upper part of the breast bare, cannot fail to render them 
more subject to the influence of cold, and the consequences of 
this cause, in the parts thus exposed. It is a fact, which has 
been forcibly pressed on my attention, that in the country — 
especially among the Germans, who are in the habit of cloth- 
ing their children in such a manner as to leave no part of the 
breast and lower portion of the neck exposed, cynanche tra- 
chealis is an exceedingly rare disease. Whereas, in cities, or 
among people who adopt the modes of dress common in cities, 
this frightful disease is, in proportion to the population, vastly 
more frequent. During a practice of six years among this class 
of people, I recollect of having met with but a single case of 
this affection, and this case occurred in a family, who had 
adopted the present universal mode of suffering the necks and 
superior portions of the breasts to remain uncovered. Certain 
exanthematous affections, also, sometimes give rise to an increased 
aptitude for this disease. This is especially the case with scar- 
latina, measles, and miliary fever. Children of robust and full 
habits, appear to be much more liable to the disease than those 
who are feeble, relaxed, and sickly. 

Cold and sudden vicissitudes of atmospheric temperature, 
constitute the principal exciting causes of this disease; and 
hence its more frequent occurrence during the variable damp 
and cold months of autumn and spring, than in the more tempe- 
rate and uniform season of summer. Sitting or lying down on a 
damp grass plat, or in a current of air after the body has been 
over-heated by exercise in the sun, is particularly apt to bring on 
an attack of this complaint. It has been observed also, that in 
situations naturally abounding in moisture, cynanche trachealis is 
a much more common disease, than in localities of an opposite 



348 croup. 

character. Under the head of occasional causes may be noticed 
also, the habit to which I have already adverted; namely, 
that of suffering the necks and upper part of the breasts 
of children to remain freely exposed to the air. I have more 
than once known this disease produced, by children throwing off 
the bed coverings at night, when asleep and in a state of free per- 
spiration from the warmth of the bed. In general this disease is 
most apt to occur soon after, or during the prevalence of epi- 
demic, catarrh, measles or scarlatina. During convalescence 
from the two latter of these affections, there exists, often, an es- 
pecial aptitude to cynanche from the influence of cold. It would 
seem, also, that the predisposition to this disease is much increased 
by having suffered an attack of it; I have known the same indi- 
vidual, suffer five or six attacks of this disease during the period 
of childhood. 

Cynanche trachealis, is a phlegmasial affection, consisting es- 
sentially, of inflammation of the mucous membrane of the supe- 
rior portion of the respiratory tube. The correctness of this 
pathology is confirmed, not only by the known character of its 
most common exciting cause, but especially, also, by the more di- 
rect evidence of the symptoms of the disease, and the appear- 
ances on post-mortem examination. Unequivocal signs of pre- 
vious inflammation are invariably discovered in the larynx and 
trachea on dissection. It is indeed surprising, that this disease 
should still be viewed by some of the German and French patho- 
logists, as essentially spasmodic in its nature, and wholly indepen- 
dent either of a general or local inflammatory condition. Several 
of the late continental writers on this disease, regard the fever 
and inflammation, which they acknowledge sometimes to exist, as 
wholly accidental, and as in no manner essential to the perfect 
constitution of the malady. Professor Nasse regards impaired or 
disordered functions of the pneumo-gastric nerves, as the proxi- 
mate cause of this disease. The characteristic symptoms of the 
disease, he asserts, bear a strong resemblance to those which re- 
sult from the division of the eighth pair of nerves. The inflam- 
mation whjch occurs in the mucous membrane of the trachea, is, 
according to his view, secondary, and a consequence of the dis- 
ordered function of the pneumo-gastric nerves. 



CROUP. 349 

There are two varieties of inflammatory croup. In one the 
inflammation commences in the fauces, and afterwards descends 
into the larynx and trachea. In cases of this kind, the breathing 
is, at first, but little affected, but the cough has a peculiarly rough 
and hoarse sound. On inspecting the fauces, the tonsils, uvula 
and palate present a swollen and dark red appearance; and the 
child always complains of considerable difficulty and pain in 
swallowing. In the other, and most common variety of the com- 
plaint, the inflammation commences in the larynx or trachea, the 
fauces remaining entirely free from redness and swelling. The pa- 
tient experiences no pain in swallowing, and the respiration is much 
oppressed from the commencement of the disease. The former 
variety is, generally, much slower in its progress than the latter, — 
the hoarse cough and occasional spells of difficult breathing, con- 
tinuing sometimes for four or five days, before the symptoms ac- 
quire a very alarming degree of violence. 

The inflammation which occasions the characteristic phenomena 
of the disease, does not always remain confined to the larynx and 
trachea. In some instances it extends downwards into the bron- 
chia, and sometimes even into the smallest ramifications. This 
extension of the inflammation is always attended with the utmost 
degree of danger; and when it passes down into the extreme 
bronchial tubes, the result, indeed, must almost inevitably be 
fatal. In cases of this kind death usually takes place from effu- 
sion into the air cells. 

In many instances the viscid albumenoid fluid, which is so co- 
piously secreted by the inflamed lining membrane of the larynx 
and trachea, concretes, over the internal surface of these passages 
into a sort of membrane; and to this membraneous substance many 
of the latter and fatal phenomena of the disease are usually 
ascribed. It must not be supposed, however, that such a pseudo- 
membrane is formed in all fatal cases; nay, it is quite certain, 
that it does not occur, even in the majority of cases. 

In other instances, the inflammation instead of giving rise to a 
concrete membraneous substance, terminates in the secretion of a 
muco-purulent fluid, of an opake and yellowish appearance. 
There are other cases again, and these are probably, the most 
common, in which the inflammation produces neither false mem- 



350 croup. 

brane nor a puruloid matter, but an extremely copious secretion 
of a very viscid, transparent and frothy mucus. Blaud thinks that 
these different modes of termination, constitute good grounds for 
dividing the disease into three principle varieties, indicating three 
different grades of inflammation. It is not improbable indeed, 
that the inflammation is at its highest grade of violence in those 
cases which are attended with the formation of a false membrane. 
It would appear to be less intense, when, instead of this coagula- 
ble exsudation, there is only a muco-purulent secretion formed; 
and where the secretion consists, simply of tough, transparent and 
frothy mucus, the inflammation is doubtless at its lowest grade. 
In the first and most aggravated variety of the disease, the 
cough and respiration are dry or free from that peculiar rattling 
sound in the respiratory passages, which occurs when these con- 
tain viscid secretions. In cases of this kind, the patient generally 
experiences considerable pain in the larynx, and the fever is usual- 
ly very strong. The period at which the false membrane is 
formed, after the commencement of the inflammation, appears to 
vary considerably. M. Blaud states that he has found the larynx 
and trachea lined with pseudo-membraneous matter, in cases 
whose whole course did not occupy more than twenty hours; 
whilst in other instances several days appeared to elapse before it 
was formed. Occasionally only a part of the internal surface of 
larynx is found lined with this concretion; but in some cases it 
extends down into the bronchia, and even into the smaller ramifi- 
cations. Sometimes instead of a membraneous expansion, the 
upper part of the trachea is found almost entirely blocked up with 
a thick mass of concreted albumenoid secretion; and this is gen- 
erally located just within the glottis. I have seen an instance of 
this kind, in which the opening left through this concreted mass 
would hardly admit a crow's quill. 

When the cough and respiration become humid or rattling, 
as soon as the inflammation is developed, we may infer that 
there will be no membraneous concretion formed. Mr. Blaud 
thinks, that the viscid mucus which is so copiously secreted in 
these milder cases, is entirely different in its properties, from the 
secretion which occurs in the former variety — and that it is 
incapable of being so inspissated as to give rise to a membra- 



CROUP. 351 

neous concrete. In these cases, the mucus in the larynx and 
trachea is often so abundant, as to threaten suffocation by 
obstructing the glottis. 

Whatever may be thought of M. Blaud's division of this dis- 
ease, or of his sentiments in relation to the radical distinction 
between the inflammation and secretion which give rise to mem- 
braneous structures, and that inflammation and its consequent 
mucous secretion which occurs in cases unattended with the 
formation of false membrane, it must be admitted that there ex- 
ists at least a two fold diversity in relation to the immediate 
local consequences of the laryngo-tracheal inflammation — name- 
ly, one variety in which false membrane is formed, and in 
which the cough and respiration are at first dry, or do not indi- 
cate the existence of much mucus in the respiratory passages; 
and another variety in which the cough and respiration are hu- 
mid, in the early period as well as throughout the disease, and 
in which a very copious secretion of transparent and extremely 
viscid mucus occurs. The former are exceedingly dangerous, 
nay, almost hopeless, unless subdued by the most prompt and 
powerful antiphlogistic measures in their very onset. The lat- 
ter are much less dangerous, and may generally be cured by 
more moderate antiphlogistic measures, and the expulsion from 
time to time of the tenacious mucus from the larynx and trachea. 
In nearly all cases the mucous membrane of the larynx and 
trachea is found very conspicuously injected on dissection; and in 
those who die under the conjoined symptoms of bronchitis and 
tracheitis, traces of inflammation present themselves, throughout 
the whole extent of the bronchial ramifications, and in some in- 
stances, the substance of the lungs is infiltrated with serum, and 
the air cells are choked up with viscid mucus. In the majority 
of cases, the glottis is narrowed by a kind of thickening or 
tumefaction of its lips. 

Considerable diversity of opinion has been expressed as to 
the immediate cause of the distressing difficulty of breathing 
and of death in this disease. In relation to the latter, it is mani- 
fest, that an impediment to the intromission of atmospheric air 
into the lungs, is the immediate cause of death, and that, there- 
fore, death occurs in this disease, from asphyxia. The circum- 



352 croup. 

stances which cause the exclusion of the air from the lungs, 
consist either in a spasmodic closure of the glottis, or in an 
occlusion of this aperture by tumefaction of its sides, or by the 
formation of false membrane or a mass of concreted lymph, or 
finally by an excessive quantity of a very ropy and viscid mucus 
closing up the passage. Death is also sometimes the immediate 
consequence of an effusion into, and consequent choking up of the 
bronchial cells, a mode of termination which almost always 
occurs when the inflammation descends into the bronchial ram- 
ifications. 

Spasmodic contractions of the glottis may be excited by the 
irritation of the concreted membraneous lymph, immediately 
within this aperture. It is a remarkable circumstance that the 
difficulty of drawing the air into the lungs is always much 
greater, and attended with much more sound than that which 
accompanies expiration or the act of throwing the air out from 
the lungs. This cannot be explained, as some have attempted, 
by supposing that the portion of the false membrane nearest the 
glottis becomes separated from the sides of the trachea, and 
that, consequently, more difficulty and noise is produced during 
inspiration, on account of a portion of the inspired current of 
air being forced in between the detached membrane and the 
surface of the larynx, whereby the ingress of the external air 
is impeded; whilst in the act of expiring the air, the detached 
extremity of the membrane would be pressed outwards against 
the sides of the treachea, and offer, therefore no particular 
impediment to the outward current of air. 

That such consequences might follow the separation of the 
superior portion of the membrane, immediately within the 
glottis, cannot be doubted; but when it is observed that the same 
relative increased difficulty of the inspiration is present, in all 
instances, from the very commencement of the disease, and before 
any membraneous concretions can be formed, we are forced to 
admit that, the circumstance in question, depends on some other 
morbid condition of the parts, implicated in the disease. 

The solution of this problem must I think be sought for in the 
altered sensibility of the glottis and trachea, in consequence of 
which the contact of the atmospheric air, produces an irritation 



croup. 353 

which excites spasmodic contraction in the glottis. It is well 
known how greatly the vital properties are altered by inflamma- 
tion. In drawing the external air into the trachea, it irritates 
the mucous membrane, and excites the glottis to contraction, by 
which the ingress of the air is retarded, and the difficulty in 
question produced. This is entirely analogous to what occurs 
in other organs when in a state of inflammation, from the impres- 
sion of their appropriate stimuli. Thus light to a healthy eye, 
is any thing but disagreeable; yet when this organ is inflamed, 
even a moderate degree of light, gives rise, to pain, and an 
involuntary contraction, or closing of the eye-lids. When the 
urethra or the neck of the bladder is inflamed, the contact of the 
urine often excites so much spasm of this canal, as to prevent the 
discharge of this secretion altogether. In a similar manner 
therefore, we may conceive, is the increased difficulty of inspira- 
tion produced in this affection. 1 wish to be understood, however 
as referring here only to the comparative difference of the acts 
of inspiration and expiration, for the dyspnoea taken as a general 
symptom, is undoubtedly mainly dependent on the circumstances 
already mentioned — namely, tumefaction — viscid mucus adhering 
to the glottis, and in the advanced stages concreted pseudo- 
membraneous substances diminishing the calibre of the respira- 
tory tubes ; and finally effused lymph or mucus into the bronchial 
cells. During expiration, the air ceases to irritate the glottis in 
consequence of its more elevated temperature, which is now on 
a level with that of the inflamed organ; and probably also, in a 
degree, in consequence of the carbonic acid which it contains 
and which is well known to be a very considerable sedative to 
irritable parts. 

Prognosis. — Cynanche trachealis is always to be regarded as a 
very dangerous affection. Formerly the majority of cases ter- 
minated fatally; but under the present improved pathology and 
mode of treatment the mortality from this disease is greatly di- 
minished. When early attended to, this complaint is, indeed, as 
much under the control of vigorous antiphlogistic measures, as 
any of the more serious phlegmasial affections. In general, the 
obstinacy and dangerousneas of the disease, is proportionate to 

2Z 



354 croup. 

the intensity of the inflammation, and the extent to which it 
passes downwards into the lungs. When the fever and croupy 
symptoms come on suddenly, the danger is, usually, much greater, 
than where the disease is slowly developed. A sudden attack with- 
out/ever, however,is not,in general, attended with peculiardanger; 
for in this case, the affection is, probably, purely spasmodic — a 
form of croup much more manageable than inflammatory or 
febrile cynanche. The shriller and more sonorous the cough is, 
the more reason is there to apprehend danger. The prognosis 
in this affection is, often, extremely uncertain. Sometimes, when 
the symptoms appear to be in a great degree subdued, and every 
thing promises a speedy recovery, a violent exacerbation will sud- 
denly supervene, and destroy the patient. On the other hand, 
death may appear to be impending, when, on the sudden expul- 
sion of a membrane, or even without such an occurrence, a rapid 
change for the better will ensue, and lead on to full convalescence* 

Diagnosis. — There' is a disease which, in most of its prominent 
symptoms, bears so close a resemblance to tracheitis, that many 
have been induced to regard it as the same affection, or at most 
as only a modification of the disease now under consideration. I 
allude to the acute astkma of Miller, or the disease which by some 
pathologists is denominated, and with perfect propriety, spasmodic 
croup. Although attended with the same extreme difficulty of 
breathing and sense of impending suffocation which belong to 
inflammatory croup, spasmodic croup is essentially distinct in its 
pathological character from the former disease, and of course 
requires a mode of treatment correspondingly modified. An 
attention to the following circumstances will enable us to distin- 
guish these two forms of croup from each other. 

1. The approach of cynanche traxhealis is generally gradual, and 
preceded by the usual train of precursory symptoms, which usher 
in catarrhal affections. Spasmodic croup, on the contrary, almost 
always comes on suddenly, and is rarely preceded by the ordinary 
premonitory symptoms of catarrh. It is true, indeed, that in 
some instances, cynanche trachealis also, supervenes quite sud- 
denly; but when this is the case, it is always so manifestly of an 
inflammatory character, and is attended with so much fever, that 



croup. 355 

there can be no difficulty in distinguishing it from the spasmodic 
variety of the disease. 

2. Cynanche trachealis is essentially a febrile disease — the phe- 
nomena of fever being never absent. Spasmodic croup, on the 
contrary, is entirely free from fever, except it be present, as an 
accidental occurrence-. In the former, the urine is almost, inva- 
riably, high-colored and scanty: whereas, in the latter affection, 
it is usually pale, watery and often copious. 

3. Cynanche trachealis is often attended with considerable 
remissions;- but these are generally of very short duration and 
incomplete. Entire intermissions, except immediately after vom- 
iting, or on the approach of syncope from "bleeding, never occur. 
In spasmodic croup, the intermissions are often complete and pro- 
tracted; and this circumstance, perhaps more than any other, 
characterizes this form of croup. 

4. Cynanche is always attended with a peculiar hoarse and 
sonorous cough, and frequently with a copious secretion of viscid 
mucus in the trachea. Spasmodic croup is rarely associated with 
much cough, often none at all, and it is always dry. 

5. The peculiar ringing sound of the cough and inspiration, so 
characteristic of cynanche trachealis, does not occur in the spas- 
modic form of the disease. 

6. In cynanche trachealis the pulse is generally frequent, full, 
quick and tense, and the skin is hot, except towards the fatal termi- 
nation of the disease, when from the imperfect performance of the 
respiratory function, animal heat ceases to be generated with due 
rapidity, in consequence of which the extremities and surface gen- 
erally, became cool or cold. In spasmodic croup, on the other 
hand, the pulse is small, very frequent and feeble, and the skin 
not above the natural temperature. 

Dr. Rush has given an account of a post-mortem examination 
of a child, that had died of spasmodic croup. In this subject, no 
membrane, nor even any unusual quantity of mucus, was found in 
the respiratory passages; and the trachea as well as the lungs ex- 
hibited a perfectly healthy appearance. It is, indeed, sufficiently 
ascertained, that cases of a purely spasmodic character occur, 
which in the extreme difficulty of breathing and other phenomena, 
bear a strong resemblance to cynanche trachealis. This form of 



356 CROUP. 

the disease is evidently of the nature of spasmodic asthma, and 
appears to depend on cerebral or dental irritation, by which the 
functions of the respiratory nerves are thrown into disorder. 

Treatment. — The principal objects to be kept in view, in the 
treatment of this affection, are: to subdue the local and general 
inflammatory irritation; and to promote the discharge of the 
viscid and concrescible secretions, which are lodged within the su- 
perior portions of the respiratory tube. Fortunately the remedies 
which are found most efficient, in the accomplishment of the lat- 
ter object, are also among the most useful auxiliaries for the re- 
duction of the febrile excitement and local inflammation. With- 
out doubt, however, the remedy upon which our principal reliance 
should be placed, for the removal of the tracheal inflammation is 
blood-letting. In the whole catalogue of inflammatory affections, 
there is no disease, in which bleeding when promptly and efficient- 
ly practised, is more likely to prove beneficial, than in the one now 
under consideration. He who, in violent cases, neglects this im- 
portant measure, and places his hopes on one or more of the em- 
pirical remedies, that have, by different practitioners, been ex- 
tolled for their supposed specific tendency to counteract the trache- 
al affection, will, we may be assured have but little reason to 
flatter himself for his success in the management of this malady. 
Here, however, as in most of the other phlegmasial diseases, the 
beneficial effects of bleeding, are limited to the early period of 
the complaint. If bleeding be neglected, or inefficiently em- 
ployed in the first stage of the malady, its progress will be ex- 
tremely perilous, whatever other remedial measures may be 
adopted. When called to a patient labouring under a severe at- 
tack of this disease, a vein should be immediately opened, and 
the blood suffered to flow until a very decided impression is made 
on the pulse, or until an approach to syncope is induced. When 
blood is thus efficiently drawn, all the distressing symptoms usually 
subside for a time; and in some instances this first blow at the dis- 
ease, subdues its strength so far, as to prevent it from afterwards 
recovering any alarming degree of violence. More frequently, 
however, the fever and difficulty of breathing, rise again in the 
course of an hour or two, and when this happens, and the pulse 



CROUP. 357 

be not soft and weak, more blood should be drawn, and again to 
the extent of producing a very obvious impression on the circula- 
tion and general system. I have been obliged to open a vein three 
or four times in the course of the first twelve hours, before a per- 
manent and decisive impression was made on the febrile and in- 
flammatory symptoms. My usual mode of bleeding in this disease, 
is to have the patient supported in a sitting posture, with his feet 
immersed. in warm water, whilst a vein is opened in the arm. In 
this way syncope will be induced much more readily, than when 
the patient remains in a recumbent posture during the operation. 
Nothing tends so powerfully and promptly to arrest the progress 
of inflammation as partial syncope induced by blood-letting. 
During this state the momentum of the circulation is greatly dimin- 
ished, and a general relaxation of the cutaneous exhalents ensues; 
effects which have a direct and powerful influence, in reducing 
the inflammatory condition of the system. 

Such copious depletion is, however, demanded only in cases 
where the local and general inflammatory action is strong; where 
the pulse is active, firm, quick or tense, attended with a dry and 
sonorous cough and respiration. Cases of this kind, are apt to 
terminate in the formation of pseudo-membraneous concretions in 
the larynx, and our efforts ought to be prompt and vigorous to re- 
duce the inflammation below the grade necessary for the forma- 
tion of false membrane. After the effusion which gives rise to 
these concretions has taken place,. bleeding will afford but very little 
or no advantage. Where the febrile symptoms are moderate, 
and the pulse is free from tension and hardness, and especially 
where in connection with moderate febrile irritation, the cough and 
respiration are accompanied with a copious transparent, and viscid mu- 
cus, blood-letting need very rarely be carried to the extent that 
has just been mentioned; and may even, in mild instances, be 
wholly dispensed with. 

Next in importance to prompt and decisive blood-letting are 
emetics. They are, indeed, altogether indispensable in managing 
this formidable malady, and, when assisted by warm pediluvium, 
rubefacients to the throat, and mercurial purgatives, they will of- 
ten subdue mild attacks of the disease, without the aid of direct 
depletion. When the febrile excitement is strong, however, and 



358 CROUP. 

the breathing is very difficult, with a turgid and flushed appearance 
of the face, it would be highly imprudent to rely on emetics and 
their usual auxiliary remedies, without prompt and decisive vene- 
section. Nevertheless, even where bleeding may be regarded as 
our main stay, emetics are highly useful, and ought always to be 
employed concomitantly with venesection. They are especially 
beneficial when the disease is early attended with a copious secre- 
tion of viscid mucus in the larynx and trachea. Much of the 
difficulty of breathing in cases of this kind, depends on this vis- 
cid secretion, obstructing the entrance of the air into the lungs. 
The occasional- expulsion of this glutinous fluid from the trachea, 
by the operation of an emetic, not only greatly relieves the dis- 
tressing difficulty of breathing and sense of suffocation, but con- 
tributes also to obviate the formation of false membrane, by pre- 
venting the accumulation and removal of the coagulable secretion 
in the trachea. They tend moreover, to equalize the circulation 
and to promote the cutaneous exhalation, as well as to diminish 
the general arterial excitement by the nausea which precedes and 
accompanies their operation. When the cough ahd respiration 
are dry, as they commonly are, during the first stage of highly in- 
flammatory cases, we seldom derive decided advantage from the 
operation of an emetic, so long as this dryness of the larynx and 
trachea continues. In such cases the proper period for adminis- 
tering emetics, commences with the appearance of .the viscid secre- 
tions in the respiratory passages. Without doubt, from the general 
antiphlogistic tendency of nausea and emesis, some benefit may 
result from the employment of emetics, before any morbid secre- 
tions occur in the trachea; but the peculiar usefulness of this class 
of remedies, is always most conspicuously displayed when the up- 
per portion of the wind pipe is clogged with viscid mucus. 

In the commencement of the disease, there seldom exists any 
difficulty in procuring free vomiting; but after the disease has 
continued for some time, 'or even in the beginning when the re- 
spiration is extremely oppressed, there exists, often, so much in- 
sensibility of the stomach, in consequence of the imperfect decar- 
bonization of the blood, and the sanguineous congestion in the 
brain, that great difficulty is experienced in procuring the opera- 



croup. 359 

tion of emetics. To remove this gastric torpor and procure vomit- 
ing, we must endeavour to diminish the congestion in the brain; 
and this may, in general, he readily accomplished, by putting the 
patient's feet in warm water, and applying a napkin wet with cold 
water, to the head. The abstraction of blood, also, while the 
patient is supported in a sitting or erect posture, rarely fails to 
restore the sensibility of the stomach and to ensure the prompt 
operation of emetics. 

The articles I prefer, as an emetic in this disease, are calomel 
in union with tartar emetic. I commonly administer from five 
to six grains of the former article with one fourth of a grain of 
the latter, to a child of two to five years old. This may be 
repeated every fifteen minutes until vomiting is excited. I have 
frequently given from eight to ten grains of calomel alone, and 
have generally found it to excite active vomiting in a very short 
time. The peculiar advantages, which appear to me to attend 
this practice, are the protracted nausea, which the calomel pro- 
duces, an effect which has a powerful antiphlogistic tendency; 
and the alvine evacuations which almost always speedily ensue. 
Besides these effects, benefit may also be expected from the 
early constitutional influence of the calomel — an influence which 
in the present disease especially is very generally acknowledged 
to be highly salutary. Tartar emetic, ipecacuanna, sulphate of 
zinc, squills, and the sulphate of copper, have all been used and 
recommended in this affection; and where the object is merely to 
procure the expulsion of the tracheal mucus, or perhaps pseudo- 
membraneous matter, any of these articles may answer our pur- 
pose. 1 have in some cases administered the lobelia inflata with 
a view to its emetic operation with the happiest effect. From its 
Well known powerful influence on the respiratory functions in 
asthma, independent of its emetic effects, there is reason for pre- 
suming that, in relation to the present disease, it may possess 
peculiar virtues, and my limited experience with it, inclines me 
to this opinion. When the stomach is very torpid, and there is 
urgent necessity for procuring the immediate expulsion of the 
viscid secretions from the trachea, the sulphate of zinc, will in 
general answer better than- any other article of this kind. The 
following mixture is strongly recommended by M. Jadelot as an. 



360 CROUP. 

emetic, in this affection.* In mild cases, a mixture of two parts 
of the syrup of squills, and one part of antimonial wine, given in 
tea spoonful doses every fifteen minutes, until vomiting is produc- 
ed, frequently procures speedy relief. The common hive syrup 
of the shops, is also an excellent preparation for this purpose. 
In some instances when the accumulation of the viscid secretions 
is very rapid, it becomes necessary to repeat the emetic three, 
four or five times in the course of twenty four hours. 

Purgatives are useful auxiliary remedies in the treatment of 
the disease. In the commencement of the treatment the bowels 
should be freely evacuated, by an active purgative. After this 
has been effected, it will be best to employ the gentlest articles 
of this class of remedies, so as to procure two or three evacua- 
tions daily, until the inflammation is subdued. Very active 
purging throughout the course of the disease, tends to exhaust the 
powers of the system, without affording any peculiar benefit, 
over milder aperients. After the first cathartic, it will in general 
be sufficient to keep the bowels in a loose state by laxative 
enemata. 

Calomel, given with a view to its constitutional influence, has 
been generally regarded as a highly valuable remedy in this 
affection. The late Dr. Rush placed great reliance on its pow- 
ers in croup. When given in large doses in the commencement 
of the disease and continued afterwards in small doses, " the 
Peruvian Bark," he affirms, " is hardly a more certain remedy 
in intermittents than calomel in croup." Dr. Hosack, also speaks 
very favorably of the employment of this article in conjunction 
with James' powder, given at short intervals, during the second 
stage of the complaint; and the late Dr. Bard placed much 
reliance on its powers. That the constitutional influence of 
mercury is calculated to do good in cynanche trachealis, I am 
well persuaded from my own experience. It tends to reduce the 

* R. Infus. polygalae Seneg. giv. 
Syrup. Ipecac. . . . 3'- 
Oxymil. Scillae . . 3iii. 
Antimon. Tart. . . gr. s?. 
M. Take a table spoonful every 15 minutes until vomiting is excited. 



CROUP. 361 

local laryngotracheal inflammation, and to counteract, as it would 
appear, the formation of the pseudo-membraneous concretion. 
In the more acute and rapid cases, however, many of which run 
to a fatal termination in less than twenty four hours, the constitu- 
tional operation of this remedy is much too slow to afford any 
particular advantages. Where on the contrary the disease is 
protracted in its course, or assumes somewhat of a chronic char- 
acter, great benefit may unquestionably be derived from this 
potent remedy. My usual mode of giving calomel, after the first 
or second emetic, is to exhibit one grain every hour or two, with 
about one fourth of a grain of ipecacuanna. 

Among the remedies that may be usefully employed for the 
reduction of the tracheal inflammation, the warm bath deserves 
to be particularly mentioned. Used along with the remedies 
already mentioned, its benefits are often considerable, more 
especially when the skin is very dry and harsh. It is to be 
observed, however, that its usefulness is. in a great measure, 
confined to the early period of the disease; for in the advanced 
stages of violent or unsubdued cases, the pulse is not only weak 
and very frequent, but the surface is generally bathed with a 
profuse and cold perspiration. Under these circumstances, no 
advantage but rather injury, would result from the relaxing in- 
fluence of the warm bath. 

Rubefacients and blisters are important remedies in the treat- 
ment of this affection. As soon as blood has been drawn, some 
irritating liniment, or a blister, ought to be applied to the throat 
of the patient. In general, the spirits of turpentine answer better 
for this purpose than any other rubefacient we possess. Its action 
on the skin is very prompt and powerful; and if the derivative 
owers of such applications be proportionate to the degree of 
irritation and pain they produce, few articles can equal the pre- 
sent one in this respect. A piece of flannel may be imbued with 
the turpentine and applied round the neck. Children seldom bear 
this application more than twenty or thirty minutes at a time. It 
should therefore be removed and reapplied, from time to time, 
according to the violence and permanency of its effects upon the 
skin. The oil of the monarda punctata, with an equal proportion 

3A 



362 croup. 

of camphorated liniment, forms, also, an excellent rubefacient in 
this affection. 

Judging from my own experience, I am induced to prefer the 
employment of rubefacients to that of epispastics. The former 
have always appeared to me to do as much good as the latter, 
and they possess the great advantage of acting with great promp- 
titude — a circumstance of no small consideration in a disease 
which often runs its fatal course in a few hours. A blister requires 
four or five hours before its effects on the skin can be of any par- 
ticular avail; whereas the impressions of some of the essential 
oils are almost instantaneous. Nevertheless, where the disease 
proceeds slowly, blistering will be highly beneficial, and should 
not be neglected. 

Local bleeding, by leeching, does not appear to make obvious 
impression on the tracheal inflammation; and it is now seldom if 
ever resorted to, except where the disease is attended with inflam- 
mation and swelling with the tonsils and palate. In one instance, 
in a child about six years old, I have known cupping on the back 
of the neck to procure manifest relief; but this case, was asso- 
ciated with conspicuous inflammation in the fauces. 

Formerly, the root of the polygala senega was held in high esti- 
mation as a remedy in this disease; and it is unquestionably a very 
useful medicine in certain states of the disease, although, most as- 
suredly, far from possessing the powers which were at first ascrib- 
ed to it by Archer and others. In the commencement of the 
complaint — more especially in violent cases, this article is objec- 
tionable on account of its stimulating properties; but after the 
general and local inflammatory irritation has been to a considera- 
ble degree subdued, or the disease has lost its acute character, or 
assumed a chronic form, it is often highly beneficial. When a 
dry and hoarse cough, with slight difficulty of breathing remains, 
after the inflammation has been subdued, the polygala will in 
general prove more useful than any other remedy we possess. In 
all chronic croupy affections, and in the catarrhal sequela of this 
and other accutc affections of the respiratory organs, it is a rem- 
edy of very excellent powers. It should be given in decoction. 
An ounce of the root to a pint of boiling water, simmered down 
to about three gills and sweetened with honey forms a suitable 



CROUP. 363 

preparation. From one to two or three tea spoonfuls of this de- 
coction should be given every hour or two, according to the age 
of the patient and the urgency of the symptoms. 

The hepar sulphuris (deuto-sulfure of potassium) was introduced 
to the notice of the profession, as a remedy in this disease, about 
twenty years ago, in a prize essay on cynanche trachealis, pre- 
sented to the French Ecole de Medicine.* Its introduction was 
founded on the erroneous doctrine that croup consists essentially in 
a morbid coagulability of the tracheal mucus, and which, it was 
asserted the sulphuret of potash had the power of preventing or 
correcting. It need, scarcely, be observed, however, that a rem- 
edy, which might possess such a power, without, at the same time 
exerting any influence in subduing the inflammation, could afford 
but little advantage in this affection; and the result of later ex- 
perience goes to show that this, at first highly lauded remedy, 
exerts no obvious influence over the tracheal inflammation — and 
it is accordingly, now, very properly, universally abandoned. 

When called to a patient labouring under this disease the fauces 
should be carefully inspected. It is now well ascertained that the 
albumenoid exudation which forms the false membrane, often 
commences on the surface of the inflamed tonsils, and thence 
spreads along the arches of the palate, and at last descends into 
larynx and trachea. In such cases the fauces will be found 
tumefied and of a dark red colour, and whether there be any ap- 
pearance of false membrane or not, immediate attention should 
be paid to this inflammation. Dr. Mackensie, states that the ap- 
plication of a solution of the nitrate of silver, to the tonsils and soft 
palate, will, in such cases, often remove the membraneous crust 
completely, and procure speedy and great relief, and ultimately 
an entire removal of all the dangerous symptoms. "The solution 
which I employ," says Dr. Mackensie, "is a scruple of the nitrate 
of silver in an ounce of distilled water. By means of a large 
camel hair pencil, this solution is to be freely «^p'lied, once, or 
twice a day according to the severity of the symptoms, to the 
whole lining membranes of the fauces. The surface of the ton- 
sils, or wherever else the fibrinous crust is actually in view will of 
Rapport sur les ouvrages envoyees au concurs, sur le croup, par la commission 



364 CROUP. 

course be particularly attended to; but I do not hesitate to push 
the pencil to the lower part of the pharynx. This remedy so far 
frcm being productive of any irritation beyond the mere mechani- 
cal and temporary one attending its employment, uniformly alle- 
viates the symptoms of the croup, such as the difficult respira- 
tion, the barking cough, and the peculiar anxiety of the little 
patient." 

In one instance which came under my notice, this application 
was decidedly beneficial. Laennec has published an account of 
some cases from which it appears that insufflation of very finely 
powdered alum, generally affords speedy relief, not only in this 
variety of the disease, but also in cynanche laryngea and tonsil- 
laris. I have recently prescribed in a case of this kind, in 
which I derived unequivocal advantage from this remedy. Four 
or five grains of finely powdered alum should be introduced into 
the end of a small tube, (the barrel of a quill will answer,) and 
forcibly blown into the fauces. This practice appears to me of 
the utmost importance in cases of this kind, and ought never to 
be neglected, where the fauces on inspection, present an irritated 
and inflamed condition. Success in the treatment, must depend 
materially on the prompt reduction of this primary extra laryn- 
geal inflammation. 

With a view of expelling the false membrane, emetics have 
been recommended in the advanced period of the disease, and 
the records of medicine are not wanting in instances in which 
this object was effected by such a measure. It offers, however, 
but and exceedingly slender foundation to build any hopes upon. 
The same object has in one or two instances been obtained by 
exciting violent sneezing by blowing snuff into the nostrils 
through a small tube. As to the proposed operation of tracheo- 
tomy in order to detach and remove the membrane, all experience 
has so far decided against it. 



CYNANCHE LARYNGEA. 365 



CHAPTER XXXI. 



CYNANCHE LARYNGEA. 



This disease generally commences with a slight sensation of 
chilliness, alternating with flushes of heat, attended with a feel- 
ing of soreness in the fauces, more or less tenderness to pressure 
about the top of the thyroid cartilage, and some pain and diffi- 
culty of swallowing. The voice soon becomes changed into a 
thick, hoarse whisper, and on strong inspiration the air seems to 
enter into the trachea with difficulty, or as if it were forced 
through a very narrow aperture, and is attended with a dull rough 
sound. On inspecting the fauces, the tonsils, soft palate, and uvula, 
present a bright red, and cedematous appearance. There is sel- 
dom much expectoration, but the saliva is usually abundant and 
of a very viscid character. The febrile symptoms are not vehe- 
ment, the face being for the most part pale, and the pulse fre- 
quent, small and tense. The tongue is covered with a thin white 
fur, over which a thick layer of transparent mucus is spread. As 
the disease advances, deglutition becomes more and more painful, 
and is apt to excite alarming and distressing paroxysms of suffo- 
cative breathing. The temperature of the surface is very 
unequal, some parts being very warm, whilst others are preter- 
naturally cool. Dr. Armstrong observes, that the most peculiar 
and characteristic symptom of this affection, is the total inability 
to cough out, as is done in pneumonic and catarrhal complaints; 
the attempt to do so, resulting in a kind of suppressed or 
suffocative effort, terminating " in a low, grumbling and almost 
grunting sort of noise in the throat." The difficulty of breathing 
increases progressively as the disease advances, with frequent dis- 
tressing paroxysms of dyspnoea, until, in unsubdued cases, death 
at last occuts by actual suffocation. 

The disease sometimes approaches in a very gradual and 
insidious manner, the symptoms for a day or two, resembling 



366 CYNANCHE LARYNGEA. 

those of ordinary catarrh, with slight hoarseness. In some 
instances, it comes on suddenly and in a very short time acquires 
a fatal degree of violence. Mr. Porter relates two instances, 
where the individuals went to hed at night, without complaining 
of any illness, " and were found dead from this affection, the 
next morning." A case is also reported by M. Leville, which was 
so marked by erysipelas of the face, as to escape observation 
until within a few hours of its fatal termination.* 

Cynanche laryngea may be distinguished from croup, by the 
following circumstances. In this affection there is always pain 
experienced in the larynx, generally referred to the top of the 
thyroid cartilage. Deglutition, too, is invariably painful and 
difficult, and after the disease is fully developed, often wholly 
impossible. On inspecting the fauces they are found somewhat 
swollen and inflamed; and every attempt to swallow brings on 
a paroxysm of suffocative breathing. None of these symptoms 
occur in cynanche trachealis, except occasionally swelling and 
■ inflammation of the tonsils and palate. 

" The seat of this affection is more in the cellular tissue con- 
necting the mucous membrane with the adjacent parts than in the 
membrane itself, although this latter structure is very frequently 
in an inflamed condition."! The tonsils, soft palate, larynx, and 
epiglottis are always tumefied, red, and in some instances vesicated. 
The rima-glottidis, also, is in general, so much swollen as nearly 
to close, the aperture. The swelling of these parts appears to 
be cedematous, depending, mainly, on the effusion of serum into 
the submucous cellular tissue. Sometimes the inflammation is 
confined to the larynx, but in some cases, it extends down into 
the, trachea and even into the bronchia. (Armstrong.) The 
principal seat of the inflammation, however, is in the epiglottis, 
which is usually " red, erect, cedematous, and during life resembles 
a piece of raw meat." (Porter.) Cases have occurred in which 
the inflammation terminated in the formation of one or more 
abscesses in the cellular tissue surrounding the larynx. 

* Gazette de Sante 1827. 
t Observations on the Surgical Pathology of the Larynx and Trachea, &c. By Wm. 
Henry Porter, p. 98. 



CYNANCHE LARYNGEA. 367 

ireatment. Laryngitis is a most rapid and dangerous affection. 
It often terminates fatally in less than twenty four hours, under 
the most energetic and judicious course of treatment. Blood-' 
letting does not appear to exert the same degree of influence in 
arresting the progress in this affection as it generally does in 
other varieties of tracheal inflammation. Dr. Armstrong declares, 
that he has known "one hundred and sixty ounces of blood drawn, 
within the space of six hours" in adult patients, without making 
the slightest impression on the progress of the malady. In only 
one out of six cases, he says, did blood-letting appear to afford 
any obvious advantage. From the occasional vesication of the 
affected parts, and the serous infiltration into the cellular tissue, 
it would seem, that the inflammation partakes more of the erysi- 
pelatous than of the phlegmonous character; and this is probably, 
the reason why bleeding though prompt and copious, exerts so 
feeble an influence over its progress. 

But although blood-letting does not often procure any promi- 
nent benefit in this affection, it is unquestionably decidedly indi- 
cated, and ought always to be promptly and efficiently practised. 
Dr. Beck of New York thinks, that the apparent inefficacy of 
bleeding in this complaint, is to be ascribed to the inadequate 
manner in which it has been usually employed. When carried to 
the extent of producing syncope, he says, it is as likely to do good 
in this as in other severe inflammatory affections of the respira- 
tory organs. My own experience, does not, however, entirely 
accord with this observation. Nevertheless bleeding to the extent 
of producing fainting, ought to be regarded as an indispensable 
measure in the treatment of this affection. After blood has been 
efficiently drawn with the lancet, leeches should be largely ap- 
plied to the throat. Martinet has reported a case, which termin- 
ated, favorably under the employment of general and local bleed- 
ing and blistering. Dr. Arnold, has, also, related a case, in which 
the use of the lancet and leeching was decidedly beneficial.* A 
blister ought to be early applied to the throat, or to the back of 
the neck. In a case which I attended about two years ago, very 
obvious benefit was derived from blistering the back of the neck, 
while leeches were applied to the throat. It is not necessary or 

*Med. Chir. Transact, vol 9, p. 31. 



368 CYNANCHE LARYNGEA. 

even advisable to delay the application of the epispastic until the 
momentum of the circulation has been moderated by depletion. 
The earlier the blistering is resorted to, the greater the chance 
of deriving advantage from it. Armstrong places more reliance 
on the repeated employment of antimonial emetics in this com- 
plaint than on any other remedy. After he had repeatedly failed 
in subduing the disease by blood-letting and counter-irritating 
applications, he resolved to try the effects of repeated emetics. 
He accordingly, resorted to the use of antimonial emetics in five 
cases, to which he was subsequently called; and, he declares, that 
"no circumstance in his professional life ever gratified him more 
than the great and sudden relief which vomiting afforded in 
these cases. It removed all the urgent symptoms at the time, 
and, being re-excited as soon as ever the slightest signs of stricture 
in the larynx returned, it at last completed the recovery." In a 
well marked case, which I attended a few years ago, in a child 
about four years old, blood-letting to the extent of producing 
syncope, followed by a blister to the throat, and three active 
emetics in the course of about fifteen hours, effected a cure. Pur- 
gatives, are very useful auxiliaries in the management of this com- 
plaint. The bowels should, in the first place, be freely evacuated 
by a full dose of calomel in union with rhubarb or julap; and after- 
wards kept in a loose state, by enemata, and repeated doses of 
calomel, both with a view to its aperient and constitutional opera- 
tion. In the case reported by Dr. Arnold, the symptoms, though 
checked by blood-letting, did not entirely yield, until the gums be- 
came sore from the free use of calomel. From what I have witness- 
ed in a case which occurred to me a few months ago, I am inclined 
to believe, that great benefit would, in general, be derived from 
blowing finely powdered alum through a small tube into the 
fauces. In cynanche trachealis attended with inflammation of 
the tonsils and palate, this application has within the last three or 
four years, been much employed with the happiest effect, both in 
Europe and in this country; and it seems highly probable that 
an early recourse to it in the present affection, would often do 
much good. 

Tracheotomy has in several instances, been performed with en- 
tire success in this disease; and Dr. Porter strongly recommends 



CYNANCHE LARYNGEA. 309 

the operation whenever the remedies already mentioned do not 
make an early and decided impression on the laryngeal affec- 
tion. " There are many reasons," he says, " why the practitioner 
should decide, at once, on the performance of tracheotomy, if the 
appropriate antiphlogistic measures do not afford early relief. 
Thus it allows the organ in which the inflammation is seated, to 
remain in a state of perfect repose. Considered as a wound, it 
adds nothing to the patient's danger; and as the relief it affords 
is, at least for a time, complete, it imparts confidence to the sur- 
geon, and allows him leisure to examine the symptoms and the 
remedies accordingly. If however, the operation be not early per- 
formed, it had much better be let alone altogether." Dr. Cramp- 
ton has reported a most interesting instance of the successful per- 
formance of this operation in acute laryngitis. Professor Regnoli, 
has given an account of two successful instances of tracheotomy 
in chronic laryngitis. Acute laryngitis, he observes, sometimes 
terminates in chronic inflammation and oedema of the epiglottis 
and mucous membrane of the larynx, which ultimately renders 
respiration extremely difficult, and may even cause death by suf- 
focation. In cases of this kind tracheotomy is the only means of 
relief in our power.* 

* Nuvo mercurio, delle scienze mediche. Mazat 1829. 

3B 



370 DROPSY IN THE BRAIN. 



CHAPTER XXXII. 



ARACHNITIS. HYDROCEPHALUS. DROPSY IN THE BRAIN. 

Arachnitis often makes its approaches in a very gradual man- 
ner. In many instances manifestations of an unusually irritable 
condition of the brain occur, and continue for several weeks be- 
fore the disease is fully developed. During this irritative stage of 
the disease, the patient manifests a very irritable and fretful 
temper; he is wakeful, and when sleeping he grinds his teeth, 
and often starts or awakes suddenly with violent screaming and 
a peculiar expression of alarm in the countenance. Infants cry 
frequently without any apparent cause, and often start at 
the slightest noise and shrink suddenly as if pricked with a 
pin. The bowels are generally irregular, and the evacuations 
of an unnatural appearance. This irritative condition sometimes 
continues for a considerable time, without passing into actual in- 
flammation, the child gradually regaining its ordinary state of 
health. If, however, some additional exciting causes supervene, 
such as difficult dentition, cold, or gastro-intestinal irritation from 
improper food or other offensive matters lodged in the alimentary 
canal, this irritative condition of the brain, is more or less rapid- 
ly aggravated, until it finally passes into actual inflammation. A 
new train of symptoms now ensues, which characterizes the in- 
flammatory stage of the disease. 

The patient now begins to experience transient pains in the 
head, and in most cases in the abdomen. These abdominal pains 
are occasionally very violent, but always very transient. The 
restlessness, and irritability of temper increase and the counte- 
nance is expressive of discontent and suffering. The face is 
usually pale with an occasional flush on one cheek. The eye- 
brows are, at times, contracted into a peculiar frown; and the 
eyelids generally kept in a half-closed state on account of the 
sensibility of the retina. The appetite is variable, in some in- 



DROPSY IN THE BRAIN. 371 
stances voracious, but more frequently impaired. The state of the 
bowels also is variable, being sometimes — indeed most general- 
ly torpid, and at others relaxed, the stools presenting an unnatu- 
ral appearance. As the complaint progresses the pains in the 
head become more and more severe. They are however seldom 
continuous; becoming occasionally much lighter, and at times for 
a few minutes entirely absent. The headache is chiefly seated 
in the forehead, shooting backwards and towards the temples. 
Children manifest their sufferings from this pain by almost con- 
stantly putting their hands to the forehead, and I have seen in- 
stances in which the little patient kept one of the hands contin- 
ually applied to the head, and would not suffer it to be removed 
for an instant. At this period of the disease, the stomach is apt 
to become very irritable — the retching and vomiting being some- 
times very troublesome, particularly on sitting up or taking any 
thing into the stomach. Children, affected with this disease, sel- 
dom bear the erect position without much uneasiness. I have 
met with many instances, in which the patient manifested no dis- 
position to vomit while in a recumbent posture, but the moment 
his head was raised from the pillow, sickness and vomiting en- 
sued. In the early part of the disease, however, the patient does 
not, generally, sleep easy with his head low. He is very restless, 
turning and tossing from one side of the bed to the other, and 
frequently groans, or whines, as if under the influence of pain. 
In some instances, the pain in the head, and the sickness and 
retching alternate with each other, the former ceasing as soon as 
nausea and vomiting come on. Frequent and deep sighing, is 
one of the most constant and characteristic symptoms of this mal- 
ady. It is seldom very conspicuous, however, until the disease 
has made considerable progress, and is generally most remarka- 
ble, about the time when the inflammation is terminating in effu- 
sion, and some degree of cerebral torpor and somnolency are pre- 
sent. Delirium usually, occurs, during the latter part of the in- 
flammatory stage: but it is never violent or furious, and very 
rarely so great, that the patient may not be roused from it, so as 
to give correct answers. Martinet observes that when the 
arachnoid membrane of the convexity of the brain is the princi- 
pal seat of the inflammation, the delirium is much more constant 



372 DROPSY IN THE BRAIN. 

and conspicuous, than when the base of this organ is the part 
chiefly affected. The skin, during this stage is generally dry 
and above the natural temperature; and the pulse is frequent, 
quick, and tense or sharp, but seldom full. The tongue, usually, 
remains clean, or covered only with a thin white fur, with pale 
red edges; but in cases depending on intestinal irritation, it gene- 
rally becomes loaded with a thick brown fur, which towards 
the termination of the disease becomes dark, dry and rough. 
After these symptoms have continued for an indefinite period, 
a new series of phenomena ensues, characterizing the third, or 
somnolent stage of the disease. The delirium now returns more 
frequently and continues longer; the countenance exhibits a pecu- 
liar expression of surprise and stupor, which it is impossible to 
describe, but which when once seen cannot be easily mistaken or 
forgotten. The conjunctiva, presents a suffused and reddish ap- 
pearance; the pupils are dilated or much contracted, and the 
retina, in some cases, is extremely sensible to light. During sleep, 
the eyes are generally turned up, so as completely to hide the 
cornea under the upper lids. The patient now manifests a con- 
stant disposition to sleep; he becomes inattentive to surrounding 
objects, and when roused from his stupor he soon relapses into the 
same somnolent state. There is, in nearly all cases, great torpor 
of the intellectual faculties, or an impossibility, it would seem, of 
directing them to any object, or bringing them into action, so that 
the patient can seldom be induced to utter more than monosylla- 
bles. This mental apathy and torpor does not, however, occur, 
until disorganization or effusion is about taking place in the brain; 
for in the earlier periods of the disease, there is often great ac- 
tivity of the mental faculties. The drowsiness and mental torpor 
increase more and more, until a complete state of coma ensues. 
This morbid somnolency is the most constant of all the phenomena 
of the advanced period of the disease. In no instance where the 
complaint is not early arrested, does this symptom remain absent. 
In some cases, after the febrile and inflammatory symptoms have 
continued for some time, the coma comes on suddenly, in conjunc- 
tion with paralysis of one side or of one extremity; but, it much 
more commonly supervenes in the gradual manner just mentioned. 
Indeed instances occur, in which the febrile irritation is so slight 



DROPSY IN THE BRAIN. 373 

as to escape attention, the first obvious manifestations of the dis- 
ease, being an unusual drowsiness and mental torpor. In cases 
of this kind arachnoid inflammation, is no doubt going on without 
manifesting itself by the usual local and general symptoms of in- 
flammation. It is a fact, well ascertained, that inflammation 
sometimes goes on in the brain, even to the extent of producing 
■1 disorganization, without manifesting .its existence either by 
pain or any other symptom indicative of inflammation. Soon 
after the somnolent stage supervenes, paralysis generally occurs 
on one side, or in one extremity. In infants we generally, at 
first, notice a tremulous motion of one arm with the hand firmly 
bent inwards. By degrees the power of using the arm and leg of 
one side, becomes much weakened, which, in a short time, ter- 
minates in complete paralysis. At the same time, one or both 
the upper eye-lids, usually, become paralyzed, so that the patient, 
in endeavouring to look at any thing, is unable to raise the lids by 
their proper muscles, and is therefore obliged to draw them up 
with the integuments of the forehead by the contraction of the 
occipito-frontalis muscle. Strabismus, almost always occurs, pre- 
vious to the supervention of paralysis, or deep coma. When the 
symptoms, last mentioned, namely strabismus, paralysis and coma 
occur, we may presume that disorganization or effusion has taken 
place in the brain. Soon after the inflammation has terminated 
in effusion, a sudden amendment, usually, takes place in all the 
alarming symptoms. The patient seems to have suddenly passed 
into a state tending to convalescence; and parents and friends, 
nay even physicians are apt to flatter themselves, that a speedy, 
though unexpected, recovery is at hand. This flattering calm is, 
however, almost universally fallacious, and of short continuance; 
for sooner or later, a paroxysm of convulsions suddenly super- 
venes, or the patient relapses into a state of fatal coma andi stupor, 
which, at once and forever, puts an end to all hopes of a favora- 
ble termination. Convulsions rarely, if ever, remain wholly ab- 
sent towards the fatal termination of this disease. The pulse 
which in the first and second stages of the complaint, is quick, 
frequent, and tense, becomes slow, full and generally irregular or 
intermitting, during the somnolent stage; but when paralysis, 
and especially convulsions supervene, it again becomes very fre- 



374 DROPSY IN THE BRAIN. 

quent, small, and corded. In the latter stage of the disease, 
vision, and occasionally hearing are wholly destroyed, yet general 
sensibility, or the sense of touch, usually remains to the last 
moment. Infants will sometimes readily lay hold of the nipple, 
and suck freely, although in a state of continued stupor and wholly 
deprived of the sense of seeing. The paralysis which occurs in 
the latter stage of the disease, is almost universally of the hemiple- 
giac kind. Infants are apt to keep the unaffected arm in con- 
tinued motion. 

The disease does not however always come on in the gradual 
manner or proceed with the train of symptoms just described. In 
many cases the attack commences and proceeds in a manner very 
similar to what occurs in the disease described by authors under 
the name of infantile remittent. In instances of this kind, the 
patient, after a few days' languor and drooping is seized with 
considerable fever attended with head-ache, flushing of the coun- 
tenance and tenderness of the abdomen. The fever differs from 
that which occurs in the ordinary form of the disease by being 
subject to frequent and irregularly recurring intermissions. 
During the exacerbations there is generally considerable stupor; 
the patient often screams and starts up, in a state of great alarm 
and agitation. The stomach is always exceedingly irritable — 
vomiting being often excited merely by changing the position; 
and the bowels are in a state of obstinate constipation. The 
countenance is usually expressive of terror and pain or of dejec- 
tion and intellectual torpor. 

In some cases the disease is ushered in by convulsions without 
any previous manifestations of febrile excitement. In instances 
which make their invasion in this manner, however, there is 
always some evidence of ill-health previous to the occurrence of 
the convulsions — such as a peevish and fretful temper, variable 
appetite, irregularity of the bowels, tumid abdomen, foul breath, 
swelled upper lip, starting and grinding of the teeth during 
sleep — in short, all that train of phenomena which results from 
gastric irritation in consequence of worms, or other irritating sub- 
stances lodged in the alimentary canal. I have known the first 
intimation of the presence of this almost hopeless disease, to be 



DROPSY IN THE BRAIN. 375 

coma, attended with deep sighing, cold hands and feet, pale 
countenance, and paralysis. 

Occasionally the disease commences and proceeds to the last 
stage with scarcely any other symptoms than slight febrile 
irritation, with little or no pain in the head, but a very frequent 
desire to pass urine, which is voided in very small quantities and 
with much difficulty. I attended a case a few years ago, in 
which not above a gill of urine was discharged in twenty four 
hours, accompanied with no other manifestations of indisposition, 
than a slightly feverish, and drowsy condition during the first five 
or six days. Dr. Monro, observes, that " there are cases in which 
the little patient has a desire, every hour, to pass urine." 

The liver almost always suffers considerable functional derange- 
ment in arachnitis. During the forming stage of the complaint, 
there is generally a manifest deficiency of bile in the evacuations, 
but in advanced periods, this secretion generally is not only copi- 
ous, but decidedly vitiated in its quality. This is particularly 
observed in the latter period of the second stage, or in the com- 
mencement of the third stage, when the symptoms of cerebral 
oppression are about supervening: at this period, the stools, 
frequently, consist almost wholly of dark bile and intestinal 
mucus, presenting a very dark green and glairy appearance, 
resembling, as Dr. Cheyne observes, " chopped spinage," or, in 
some instances, tar. 

Diagnosis. The characteristic symptoms of the first stage are: 
great irritability of temper; irregularity of the bowels; variable 
appetite; an irritated and quick pulse; wakefulness; and a pecu- 
liar frowning expression of the countenance. In the second 
stage: more or less continued pain in the head; torpor of the 
bowels; nausea and vomiting particularly on rising from the 
recumbent posture; irregular febrile exacerbations; a peculiar 
distressed expression of the countenance; sudden waking from 
sleep; transient and severe pains in the abdomen, alterna- 
ting frequently with acute pain in the head; a circumscribed 
flush on one cheek; intolerance of light and sound; a hot and 
dry skin, with a frequent, tense, and generally active pulse. 
When the disease has advanced to the third stage it is easily 



376 DROPSY IN THE BRAIN, 

recognized, by great drowsiness, strabimus, hemiphlegia, paralysis 
of the upper eye-lids, and finally coma and convulsions. The 
disease with which arachnitis is most apt to be compounded is 
infantile remittent fever. In this latter affection, however, the 
remissions are regular and generally complete; whereas in 
arachnitis, there is the utmost irregularity in the recurrence of 
the exacerbations and remissions, nor are they so perfect as in 
infantile remittent. Dr. Cheyne observes that the appearance 
of the stools, also, affords us a good diagnostic sign between 
these two affections. In infantile remittent the alvine evacua- 
tions are very fetid, and of a dark brown or mud-like color; 
whilst in arachnitis, they are usually of a dark green or glairy 
appearance, resembling the fresh ordure of cows. In idiopathic 
arachnitis, the abdomen, almost always becomes collapsed or 
flattened, without an increase of the alvine evacuations; whereas 
in infantile remittent, the belly is generally tumid, tense, and 
elastic. This circumstance is much insisted on by Goelis, as a 
diagnostic sign between these complaints. There is seldom much 
secretion of saliva, in arachnitis, both the mouth and nose being 
usually dry. In infantile remittent, on the other hand, the saliva 
and mucus of the nose are generally abundant. In the former 
affection, the tip and margin of the tongue are commonly clean 
and red; whilst in the latter, the whole surface of the tongue is 
covered with a thick, white fur, which becomes darker, and dry as 
the disease advances. There is almost invariably severe and 
continuous pain in the head, in arachnitis; whilst in infantile 
remittent, or worm fever, headache is a very uncommon occur- 
rence. In the latter disease, the little patient is almost constantly 
picking his lips and nose with his fingers; while in the former 
complaint he is apt to direct his hands to the forehead. In infan- 
tile remittent, moreover, the patient is often observed to have 
a movement of the deglutition during sleep, and when awake, 
he sometimes thrusts his fingers back into the fauces, as if desirous 
of removing something. These symptoms rarely, if ever occur in 
idiopathic arachnitis. In the former, the face is usually pale and 
leaden in the advanced periods of the disease; whereas in the 
latter, a conspicuous circumscribed flush often appears, on one or 
both cheeks. In arachnitis the head is generally the hottest 



DROPSY IN THE BRAEM. 377 

part of the body; in infantile remittent, the abdomen is usually 
the warmest part. " Vomiting is one of the most invariable symp- 
toms in the first stage of arachnitis, and is attended with this 
peculiar characteristic — namely, it comes on unexpectedly and 
suddenly, without being preceded by much nausea, and is more 
frequent when the patient is supported in a sitting position, than 
in a recumbent posture. If a child vomits frequently, at con- 
siderable intervals, if it be costive or the alvine evacuations are 
irregular and unnatural in appearance, if the abdomen is collaps- 
ed or flat and painful to pressure, if the urine be slimy and high 
colored, if there is much headache, and if the whole state of the 
disease manifest an obstinate or unmanageable course, then we 
have great reason for believing that the complaint is principally 
located in the head, and that, if not subdued, it must result in 
cerebral oppression." 

Although these circumstances will frequently enable us to form 
a satisfactory diagnosis, in relation to these two affections; it 
must be confessed, that in the commencement, arachnitis, is seldom 
cognizable; and that there is no symptom, which can be depend- 
ed on as characteristic of the disease, during its early periods. 

Dr. Alexander Monro has described a variety of hydrocepha- 
lus, which he calls the "hyper-acute form" of the disease, a 
form of very rare occurrence, and simulating in some of its most 
striking symptoms, inflammatory croup. "This rare form of 
the disease is very sudden in its attack. There is no previous 
headache, drowsiness, stupor, nausea, vomiting, paralytic state 
of any part of the body, or any other symptom denoting a de- 
rangement of the functions of the nervous system. It begins like 
croup. The child awakens in the night in a state of extreme 
agitation, and much flushed, and with a quick pulse; he is hoarse, 
and the sound of the voice when he inspires is similar to that of 
croup. The patient, at the onset of the disease, seems in a state 
of nervous irritation; often starts in his sleep, and in a short time, 
the disease assumes the appearance rather of a spasmodic affec- 
tion of the larynx, than of the inflammatory croup. The matter 
thrown up by vomiting, consists generally of indigested food. The 
longer the disease continues, the shriller and hoarser the voice 
becomes." 

3C 



378 DROPSY IN THE BRAIN. 

In the dissections which were made of children who died of 
"this form of disease, Dr. Monro found in one instance, the 
vessels of the pia mater at the corpora quadrigemina and tractus 
obtici, and at the origin of the eighth pair of nerves, much dis- 
tended with blood. No morbid appearance was discovered in 
the larynx and trachea." In another case, " the upper part of 
the brain, particularly the superior part of the posterior lobes, 
was covered with transparent gelatinous effusion;" and about an 
ounce of colored serum was found in the ventricles. "The vessels 
of the spinal marrow were turgid, those of the cervical portion 
of a vermillion-red color, and those of the lumbar portion of a 
dark-red hue. The eighth pair of nerves was of a deep uniform 
red color along its whole tract, as far as its branches, going to 
the lungs." 

Dr. Burns attributes this form of hydrocephalus, "to an affec- 
tion of the origin of the eighth pair of nerves, induced by the state 
of the extremity of the fifth pair, in dentition, acting on its 
origin, which is near the eighth."* 

Prognosis. The prognosis in this disease must be always ex- 
tremely unfavorable. The instances of recovery from it are 
indeed exceedingly few. In the course of twenty years' practice 
I have known but two fully developed cases, which terminated in 
health, and it has fallen to my lot to have seen, and prescribed for 
a very considerable number of patients ill with this appalling dis- 
ease. I have already adverted to the flattering but illusive truce 
which sometimes occurs in the latter period of the disease. — Often, 
in the early period of my professional career have I been induced 
to think, by this ominous calm, that I had conquered the disease; 
and to announce to the anxious friends my good hopes of a speedy 
return to health. These hopes, however, were always blasted ; 
and though taught by previous experience I have again and again 
thus hoped and thus encouraged, and always with the same painful 
conviction of the fallaciousness of this delusive interval. It is 
indeed extremely difficult to see so perfect a freedom from all the 
previous alarming symptoms, and not to flatter oneself, that 

* The Morbid Anatomy of the Brain. By A. Monro, M. D. 1827. 



DROPSY IN THE BRAIN. 379 

recovery may ensue. When we see the little patient, emerge 
from a state of intense suffering and danger, and assume the smile 
and playfulness of convalescence — when from a state of stupor 
and unconsciousness, he awakens', as it were, to the feelings and 
actions of returning health, it is not easy to persuade oneself that 
all this hope-inspiring change is but the illusive prelude to the 
last, painful struggle, which inevitably leads to the grave. 

Post-mortem appearance. — The appearances discovered in the 
brain, on dissection, are very various. In some instances the 
arachnoid membrane is minutely injected, presenting a very red 
appearance, throughout its whole intent; in others this membrane 
is found considerably thickened and opake. A purulent, sero- 
purulent, or sero-gelatinous matter, is in many cases found be- 
tween the arachnoid and pia mater; and in the greater number 
who die of this conplaint, from one to four or six ounces of serous 
fluid is effused into the lateral ventricles of the brain. — In some 
cases, however, very little or no serous fluid is entravasated into 
the ventricles or between the membranes of the brain. Martinet 
and Duchatelet, in their interesting work on this disease, state 
that in eight cases out of twenty-six, there was scarcely a trace of 
serous effusion discovered within the cranium. In cases of this 
kind, the substance of the brain, is generally found conspicuously 
altered, both in consistence and color. Considerable portions of 
the brain are sometimes completely disorganised and reduced to 
a pap -like consistence; and instances have occurred, in which a 
portion of the cerebral substances was found much indurated. 
Occasionally cases are met with, where no other manifestations of 
cerebral disease, are detected, than signs of strong sanguineous con- 
gestion in the brain, with but little serous effusion and no marks of 
meningeal inflammation or structural lesion. Not unfrequently, 
unequivocal marks of previous disease in the abdomen, are detect- 
ed, — sometimes the colon presents an enlarged and distended ap- 
pearance; at others, considerable portions of it, are so much con- 
tracted as hardly to admit of the introduction of a large sized 
bougie. Frequently we find more or less extensive portions of 
the mucous membrane of the bowels, minutely injected; and I 
have seen it extremely red, throughout the whole extent of the 



380 DROPSY IN THE BRAIN. 

small intestines. In one case, the lower part of the ileum was of 
a dark livid color resembling incipient gangrene. Dr. 1. C. Smith 
has given an account of a case of hydrocephalus, in which on 
post-mortem examination, the stomach was much contracted, and 
"on laying it open, an ulcer was found near the cardia, and the 
mucous and muscular coates, at this place were entirely destroyed, 
nothing remaining but a greenish mucus." 

Causes. — A strong predisposition to this disease, is manifestly 
hereditary, or constitutional, in some instances. The peculiar ap- 
titude to this affection, in some families, is sometimes strikingly 
exemplified. I know several families who have lost nearly all 
their children by this indomitable malady. It is difficult, if not 
impossible, to say in what this predisposition consists. It may 
be presumed, indeed, that children of an irritable habit of body, 
with a strong tendency to a preternatural determination of blood 
to the brain, are more liable to the disease than such as are of 
an opposite temperament. It has been supposed that children 
who have very large heads, are peculiarly predisposed to the 
arachnitis; but the correctness of this opinion is decidedly con- 
tradicted by experience and observation. It has been affirmed, 
moreover, that the scrophulous habit is often attended with a par- 
ticular predisposition to this complaint — an observation which 
appears, indeed, to be well founded. In a large proportion of 
instances, J)r f Mills found, on post mortem examination, unequiv- 
ocal appearances of scrophula; and out of twenty-two cases which 
came under the observation of Dr. Percival, eleven "were deci- 
dedly scrophulous." 

Among the most common exciting causes of this disease in chil- 
dren, are injuries, inflicted on the head by blows or falls. It has 
been observed, however, that injuries of this kind, rarely give 
rise to arachnitis, unless they are sufficiently violent to cause 
some degree of concussion of the brain, and my experience leads 
me to think, that there is truth in the observation. Suppressed 
discharges, and repelled cutaneous eruptions, particularly the 
sudden drying up of serous discharges behind the ears, is apt 
to give rise to this affection, more especially, when aided by the 
irritation of dentition, and intestinal disorder, A sudden and 



DROPSY IN THE BRAIN. 381 

total suppression of the diarrhoea, which frequently accompanies 
dentition, sometimes excites arachnoid inflammation, and conse- 
quent dropsical effusions in the brain. Dentition is often inti- 
mately concerned in the production of this complaint. This pro- 
cess, when difficult, is always attended with an irritable and 
irritated condition of the system, and a preternatural determina- 
tion of blood to the head. This, in itself, may be sufficient to 
excite the disease, in subjects who are predisposed to it, by con- 
stitutional habit, or from previous ill-health. It is probable, 
however, that dentition is seldom the sole cause of the disease; 
but that it most commonly acts in conjunction with other causes, 
especially with irritation in the alimentary canal. If, while den- 
tition is going on, the digestive functions become disordered from 
improper diet, or some other circumstance, or if irritation be 
established in the bowels, there will be a concomitance of causes, 
peculiarly calculated to develope this fatal malady. The ten- 
dency of intestinal irritation to occasion an undue determination 
of blood to the brain, is well known. In infancy, this determi- 
nation to the head, when long continued, is apt to give rise to 
inflammation of the brain, or the disease now under consideration. 
In middle age it frequently terminates in mental derangement; 
and in the decline of life, it is apt to result in apoplexy or palsy. 
It is believed by many, that arachnoid inflammation, or hydroce- 
phalus, during childhood, is very generally the consequence of 
intestinal irritation; and there are, in fact, many circumstances, 
which go to confirm this opinion. In very many cases, I think it 
may be safely asserted, that in a large majority of instances, there 
are unequivocal signs of intestinal irritation, both previous and 
during the existence of the disease. The variable appetite — the 
irregular action of the bowels, with the unnatural appearances 
of the alvine discharges — the tumid and tender abdomen — the 
picking of the nose, and the pale and sickly aspect of the coun- 
tenance, which so commonly precede the developement of the 
disease, all point to the alimentary canal as the original source 
of the irritation. Where this irritation exists, there is, doubtless, 
always a strong predisposition to the disease; and if to this be 
added some other exciting circumstance, such as a blow on the 
head, or the supervention of painful dentition, or general fever 



382 DROPSY IN THE BRAIN. 

from cold — or, in short, any occurrence which gives rise either 
to general arterial excitement, or local irritation of the brain, 
the liability to the disease will be greatly enhanced. Worms, 
acrid secretions, and an accumulation of fecal matter in the bow- 
els, are the most common remote causes of this disease, when it 
depends on intestinal irritation. The strong tendency of intestinal 
irritation to give rise to arachnitis and consequent serous effusion 
into the brain is often strikingly illustrated in cholera infantum. 
When it runs into a chronic or subacute form, this disease fre- 
quently terminates fatally, under all the characteristic symptoms 
of the last stage of hydrocephalus. In two instances of this kind, 
in which I had an opportunity of a post mortem examination, 
I found the traces of arachnoid inflammation unequivocal, with 
copious serous effusion into the ventricles, and between the cir- 
cumvolutions of the brain.* 

Hooping cough, when it occurs in subjects naturally predis- 
posed to the disease, more especially, when it is associated with 
a strumous diathesis, or a loaded and irritated state of the intes- 
tines, is no uncommon exciting cause of arachnitis. The violent 
and frequently recurring spells of coughing, forces the blood 
powerfully into the vessels of the brain, and where the superven- 
tion of the disease is favored by previous predisposition, or some 
other concomitant circumstance, may thus readily give rise to 
arachnitis. During the period of convalescence from measles 
and scarlatina, children seem to be much predisposed to this 
disease. 

While we give all the importance to intestinal irritation, as a 
cause of arachnoid inflammation, which it unquestionably 
demands, we must bear in mind, that this same cause sometimes 
gives rise to a form of cerebral oppression, strongly resembling 
the last stage of arachnitis, but which is, nevertheless, wholly 
unconnected with cephalic inflammation. The determination 
to the head, in such cases, results merely in a state of strong 
venous congestion of the brain, giving rise to a somnolent and 

* An interesting and striking case, in which hydrocephalic symptoms were produced 
by organic disease of the intestinal canal, is related in the Med. and Chir. Rev. July, 
1826. p. 102. 



DROPSY IN THE BRAIN. 383 

oppressed state of the system, which may be readily mistaken 
for hydrocephalus. (Cheyne.)* 

Treatment. — There are three principal indications to be kept 
in view in the treatment of arachnoid inflammation — viz. 1. to 
moderate the general febrile excitement; 2. to obviate sanguine- 
ous congestion and inflammatory irritation in the brain; 3. to 
remove those causes of irritation, which tend to produce and 
sustain a preternatural determination of blood to the brain. 

The disease is not often detected in its incipient stage, on 
account of the gradual and insidious manner, in which it usually 
makes its approaches. When it does become an object of 
medical attention at this early period of its course, every effort 
should be made to remove the sources of irritation, and especially 
to obviate all undue determination of the blood, to the head. 
With this view, it is of the utmost importance to attend to the 
state of the alimentary canal; for it is in the stomach and 
bowels, especially that the primary irritation and exciting cause 
of the cerebral congestion most commonly exists. 

Purgatives are, accordingly, the most valuable means we pos- 
sess, for preventing the full developement of the cephalic inflam- 
mation at this early period of the disease. The bowels should, 
in the first place, be freely evacuated, by an efficient mercurial 
cathartic, and afterwards kept in a loose state by the daily ad- 
ministration of small doses of calomel, succeeded by a moderate 
portion of some mild purgative. From three to four grains of 
blue pills, or a few grains of calomel should be given in the 
evening, and followed next morning by a weak dose of epsom 
salts, rhubarb, or of castor oil, and continued until the alvine dis- 
charges assume a natural appearance. At first, it may be neces- 
sary to repeat these aperients daily, for four or five days in suc- 
cession, after which it will, in general, be sufficient to administer 
them every second, third, or even fourth day, according to the 

* Some writers contend, that hydrocephalus is almost invariably a sympathetic affection. 
Dr. Yates in partfcular, thinks that this disease has almost invariably its origin in the 
irritation of some organ remote from the brain. Spurzheim admits, that the primary 
irritation is frequently located in the abdomen ; " yet anatomical dissections have con- 
vinced me," he says, " that, in the greater number of cases, the morbid appearances of 
the. abdomen are secondary of the cerebral disease." 



•384 DROPSY TN THE BRAIN. 

urgency of the symptoms. Mercurials are particularly useful in 
the incipient stage of this complaint, not only as aperients, but 
as means for correcting the functional torpor of the liver, which 
almost invariably attends the early stages of the disease. In ad- 
dition to these means, especial attention must be paid to the 
proper regulation of the patient's diet. The appetite is some- 
times very craving, during the incipient stage of the complaint, 
and it requires much care and vigilance to prevent children from 
taking improper food, or overloading their stomachs. It is of the 
utmost importance, to guard against these errors, as they never 
fail to accelerate the progress of the disease, and to render the 
most judicious remediate treatment abortive. The most simple, 
unirritating and digestible articles of nourishment alone must be 
allowed: such as boiled milk, barley-water, arrow-root, boiled 
rice, oat-meal gruel, weak beef or chicken tea, &c. All stimu- 
lating drinks must be carefully avoided. If dentition is going on, 
and the gums are swollen or inflamed, they should be freely 
divided down to the advancing teeth. Much benefit may some- 
times be derived during the initial stage of the disease, from 
the application of blisters behind the ears, or on the back of the 
neck; and in cases preceded by the drying up of discharging 
sores behind the ears, or on the head, blistering, in this way, 
should never be neglected. 

When the disease is once fully developed, prompt and decisive 
antiphlogistic measures, in conjunction with revulsive and deriva- 
tive applications are indispensable. Blood-letting ranks, of course, 
among our most efficient remediate means at this period of the 
disease, more especially, when the encephalic inflammation has 
been caused by some injury inflicted on the head, or when it is 
the consequence of some general cause, such as cold. In instan- 
ces of this kind, the pulse is almost invariably tense, quick, resist- 
ing and active; and nothing but prompt and very efficient blood- 
letting will make any decided impressions on the disease. 
Whenever the pulse is firm, and active, a sufficient quantity of 
blood should be taken away at once, .to check, conspicuously, the 
momentum of the circulation. I am inclined to believe, that if 
bleeding were carried to the extent of producing an approach to 
syncope in the commencement of the inflammatory stage, our 



DROPSY IN THE BRAIN. 385 

efforts would be more frequently crowned with success than they 
unfortunately are. " The temporal artery, or a vein in the arm, 
should be opened, and the blood allowed to flow, until a very obvi- 
ous impression is made on the system, or until the morbid actions 
of the vascular system of the brain are modified or totally changed. 
That such an effect has taken place, may be known by a pale- 
ness of the countenance, a shrinking of the features, and a ten- 
dency to deliquium; or by a diminution of, or removal of the 
heat, pain, weight, or uneasiness of the head." (Mills.) The 
blood-letting ought to be repeated, as soon as the febrile reaction 
and local inflammatory symptoms rise again. In cases depending 
on intestinal irritation, the arterial excitement is seldom very 
active. Here, blood-letting, though al.vays indicated in the early 
periods of the inflammatory stage, must be employed with more 
caution; for copious bleeding, by weakening the energies of the 
system, is peculiarly apt to increase the morbid sympathetic affec- 
tions of intestinal irritation. 

With regard to the utility of local bleeding in this and other 
forms of encephalic inflammation, different opinions are expressed 
by practitioners. Nearly all the French writers on this disease 
are decidedly in favor of the local abstraction of blood. It ap- 
pears, indeed^ very reasonable to expect peculiar advantages 
from a mode of depletion which abstracts the blood more imme- 
diately from the affected parts; and yet, in relation to the pre- 
sent disease, a contrary opinion has been expressed by several 
eminent practitioners. Mr. North, in his work on the convulsive 
affections of infants, observes, " that he never found well marked 
symptoms of determination to the head, removed by leeches, 
however freely they were applied." In cases in which the 
cephalic determination depends on intestinal irritation., this obser- 
vation is, perhaps, well founded; for the blood which may be 
thus removed from the vessels of the head, will be immedi- 
diately replaced by the continued preternatural afflux of this 
fluid. It must be observed, moreover, that so long as the momen- 
tum of the general circulation is considerable, local bleeding can 
scarcely produce any other advantages than such as would result 
from abstracting the same quantity of blood by means of the 
lancet. General bleeding is, therefore, an essential preliminary 

3 D 



386 DROPSY IN THE BRAIN. 

to the beneficial employment of leeches or cupping. After the 
impetus of the circulation has been moderated by the use of the 
lancet, leeching the temples, and along the posterior parts of the 
ears, is a valuable auxiliary in the treatment of arachnitis. It 
sometimes happens that blood cannot be obtained from a vein in 
the arm, and occasionally, not even from the temporal artery. 
In this case, the application of leeches is indispensable. They 
should be applied in large numbers, to the temples, occiput, and 
behind the ears, and the flow of blood encouraged, until a very 
obvious impression is made on the pulse, or a manifest tendency 
to syncope ensues. Dr. Mills, in his interesting paper on this 
disease, strongly recommends leeching, immediately after vene- 
section, " in order to postpone the period of the exacerbation, or 
break the chain of diseased action. I have observed that these 
two modes of drawing blood, when successively employed, make 
a greater impression on the disease than either of them is capa- 
ble of effecting when singly had recourse to." 

Purgatives are among our most useful means for subduing this 
disease. When the bowels are loaded with irritating substan- 
ces, and the cerebral affection is symptomatic of intestinal irrita- 
tion, laxatives are, in truth, the main stay of our hopes. They 
are, indeed, almost equally useful in idiopathic arachnitis; for 
besides their effect in evacuating irritating causes, they tend, 
very particularly, to diminish the afflux of blood to the brain, and 
to moderate the general^ momentum of the circulation. '''Should 
we ascertain," says Dr. Cheyne, " that the alimentary canal is 
torpid, and imperfectly performing its functions, admitting an 
accumulation of feculent matter; or that the secretions flowing 
into it are vitiated or diminished in quantity — circumstances 
which we ascertain by the peculiarity in the appearances, or the 
pungent fetor of the stools, we must, by steadily pursuing the 
purgative plan, endeavor to effect a change; for while this is 
produced in the appearance of the stools, we are effecting a most 
important change in the hepatic system, alimentary canal, and 
all the parts including every organ essential to life, which is con- 
nected with them." In symptomatic cases, depending on pri- 
mary irritation of the alimentary canal, the milder purgatives 
after the first thorough evacuation of the bowels, will, in general, 



DROPSY IN THE BRAIN. 387 

be more beneficial, than the repeated use of very active purges. 
Frequent purging, by the more active and irritating cathartics, 
though at first apparently useful, tend, ultimately, to increase the 
inflammatory irritation of the bowels, and consequently, the cere- 
bral affection. It must be recollected that intestinal irritation is 
not always dependent solely on the presence of acrid or irritating 
substances in the bowels. The mucous membrane of the alimen- 
tary canal may be in a state of sub-acute inflammation, or of high 
vascular irritation. In cases of this kind, the milder laxatives 
are manifestly more appropriate than the more irritating articles 
of this class, since they are sufficient to evacuate the contents of 
the bowels without causing injurious irritation. Undoubtedly, the 
first purgative should be sufficiently active, to evacuate the intes- 
tines freely. From five to six grains of calomel, followed in a 
few hours, by infusion of senna and manna, or a suitable portion 
of epsom salts, will answer well for this purpose. The bowels 
must afterwards be regularly evacuated, so as to procure three 
or four discharges daily, by the use of small doses of calomel, 
promoted by castor oil, and laxative enemata. 

In idiopathic arachnitis, however, the intestines are generally 
very torpid, and can seldom be sufficiently moved by the milder 
purgatives. In cases of this kind, it is often necessary to resort 
to large doses of the most active cathartics, in order to procure 
adequate evacuations from the bowels. The same difficulty 
sometimes occurs, in cases attended with a great accumulation 
of fecal matter in the intestines. Calomel should always enter 
largely into the purgatives employed in this disease. Independ- 
ent of its aperient effects, its constitutional or specific influence, 
if early obtained, is sometimes attended with great benefit. 
From one to three grains may be given every three or four hours, 
according to the age of the patient, with an occasional dose of 
of castor oil, infusion of senna, or epsom salts. Where there is 
reason to suspect the presence of worms in the intestines, anthel- 
mintics should be employed, in conjunction with purgatives. 
An infusion of spigelia with a small portion of senna, may be used 
with a prospect of much advantage in such cases. In some 
instances the stomach is so irritable in this disease, that no arti- 
cles will be retained a sufficient time to operate on the bowels. 



388 DROPSY IN THE BRAIN. 

Where this state exists, we must endeavor in the first place, to 
allay the gastric irritability, and this may in general be effected 
by minute doses of calomel and ipecacuanna: the one sixth of 
a grain of the former, in union with one-fourth or one-third of 
a grain of the latter, has repeatedly succeeded in my hands to 
restrain the tendency to vomiting in this disease. 

Mercury, as has been already observed, is undoubtedly a rem- 
edy of valuable powers in the treatment of this affection. Doctors 
Percival, Dobson, Rush, Cheyne, Mills, not to mention many 
other names of great celebrity, have related instances which 
yielded to the influence of this potent remedy. Employed with 
a view to its constitutional operation, mercury often contributes 
very powerfully to the reduction of visceral inflammation; and 
experience has shown, that in the present affection, it deserves to 
be regarded as one of our most valuable remedies. It is, in 
general extremely difficult to procure the constitutional influence 
of mercury, to an obvious extent, in very young children; and 
hence, to obtain this desirable object sufficiently early to derive 
decided advantage from it,, many have advised the use of mer- 
curial frictions at the same time that calomel is administered in- 
ternally. Dr. Mills of Dublin, strongly recommends the use of 
calomel in union with opium, " as soon as a check has been given 
to the disorder of the head," by venesection, leeching and purga- 
tives. " The good effects," he says, " of a combination of these 
remedies, seem to depend on their power of equalizing the circula- 
tion, increasing the secretions, and exciting the action of the 
cutaneous vessels." I cannot bring to my recollection a single 
instance, in which this remedy, when judiciously administered, 
after depletion, was followed by disagreeable consequences; and 
in cases unaccompanied by great irritability of the stomach, its 
powers are occasionally increased by the addition of small quan- 
tities of ipecacuanna, or antimonial powder."* The " watery 
extract," he thinks, is decidedly the best preparation of opium 
for this purpose. " It procures rest, diminishes pain and irrita- 
tion, and diffuses throughout the frame an agreeable sensation, 
at the same time that it is devoid of any narcotic or nauseating 

* Transact, of the King and Queen's College of Physicians in Ireland. Vol. v. 



DROPSY IN THE BRAIN. 389 

quality, and does not cause vertigo, pain, or a sense of fulness 
in the head." My own experience enables me to bear testimony 
in favor of this preparation; for I have seldom known it to 
produce the disagreeable effects that are so apt to follow the use 
of laudanum or opium, in its ordinary state. 

Dover's powder, also, has found advocates as a remedy in this 
disease. Drs. Brooke, Percival, Cheyne, and Crampton,* all 
speak favorably of its employment in hydrocephalus. After 
adequate depletion and purgation, in cases connected with 
intestinal irritation, small doses of this composition often prove 
highlv serviceable, by allaying general irritability and inducing 
a gentle diaphoresis. It should be observed, however, that in 
the idiopathic form of the disease, opiates of every description, 
must be carefully avoided, as their tendency to increase the 
f ow of blood to the brain, could hardly fail to prove very injuri- 
ous. "When preternatural determination to the head depends 
on a remote focus of irritation — as in the mucous membrane of 
the bowels — opiates, by diminishing nervous excitability as well 
as local irritation, will frequently reduce, also, the irregular de- 
terminations which depend on such irritations. It is in cases of 
this kind only, that we may venture on the exhibition of Dover's 
powder, and not in these instances until the impetus of the cir- 
culation has been moderated, and the alimentary canal well 
evacuated. 

Dr. Stocker, of Dublin,! speaks very favorably of the use of 
James 1 powder in hydrocephalic affections. According to his 
observations, it tends, very considerably, to lessen the determina- 
tion of blood to the brain. It should be given in small but 
frequent doses, and may be very properly administered in union, 
with calomel. Dr. Monro states that he has cured several cases 
of this disease by a plaster composed of tartar emetic and wax 
ointment, applied to the head, in conjunction with the internal 
use of calomel combined with James' powder. He states, that 
he has found this combination peculiarly useful, in restoring the 
healthy action of the bowels. Tartar emetic, also, has been used 

* Transactions of the Associat. of Fellows and Licentiates of the Queen's College 
of Physic in Ireland. Vol. vii. 
t Dublin Medical Essays, 1806. 



390 DROPSY IN THE BRAIN. 

with great advantage in this disease, Laennec, has reported 
some cases of acute hydrocephalus, in which he administered 
twelve grains and more of this article during the day, with com- 
plete success. 

Mr. Newnham asserts, that green tea has a strong tendency to 
lessen morbid vascular excitement in the brain. "In the acute 
irritation of the membranes of the brain in children," he says, 
" the efficacy of green tea has been strongly marked in my 
practice. Exhibited during the early symptoms, as soon as a 
sufficient quantity of blood has been taken, and before effusion 
occurs, it has proved a more powerful means than any other we 
possess, of controlling the morbid action, which, if suffered to 
proceed to its second stage, is scarcely to be overtaken by any 
treatment."* 

Nothing is more common in the treatment of this disease, than 
the application of blisters to the shaven scalp; but this practice 
is, I conceive, of very doubtful propriety. I have always pre- 
ferred placing them on the back of the neck or behind the ears, 
while ice or cold water is applied to the top of the head, and 
warm or rubefacient applications made to the feet. Dr. North, 
whose interesting work I have already mentioned, observes, 
" that blisters to the head are decidedly prejudicial in the convul- 
sive diseases of infants;" and the same observation is applicable, 
I think, to the disease under consideration. The application of 
ice or iced water, in the manner mentioned in the last chapter, 
may be accounted a very useful auxiliary in the treatment of 
arachnitis, and to favor its revulsive influence, warm or stimu- 
lating applications to the feet may be usefully employed. Dr. 
Regnault recommends in very strong terms, the application of 
moxa in this complaint;! and its known efficacy in subduing 
deep-seated articular inflammation, justifies the expectation of 
considerable advantage from its use in arachnoid inflammation. 
Neither this application nor blisters, however, should be resorted 
to, until the activity of the circulation is reduced by general and 
local blood-letting. The tartar-emetic ointment also may be 
yery beneficially applied. (Monro.) 

* Med. Chir. Rev. July, 1827. 

t Medical and Physical Journal, Vol. xi. p. 16. 



PERITONITIS. ASCITES. 391 



CHAPTER XXXIII. 



PERITONITIS. ASCITES.* 



Subacute or chronic inflammation of the peritoneum, and 
consequent effusion of serum into the cavity of the abdomen, is 
not a very uncommon disease among children. Its progress 
through the first or inflammatory stage, is often so obscure as to 
escape particular attention, until effusion has taken place, and the 
abdomen has become tumid and tense. In many instances slight 
pains are occasionally experienced in some part of the abdo- 
men, which are usually ascribed to flatulency or disorder of the 
bowels. The patient manifests a sullen and fretful temper, and 
is disinclined to engage in the usual amusements and sports of 
children. When pressure is made on the abdomen, a sensation 
of soreness is felt, in certain parts, generally about the umbilical 
region; and the same effect sometimes results from coughing, 
sneezing, or any sudden concussive motion of the body. At night 
the patient is restless, and his sleep is broken and " of shorter 
duration than formerly." The face and whole surface of the 
body are pale, and the countenance expressive of discontent, suf- 
fering and languor. The appetite is variable; the tongue cov- 
ered with a white fur along the middle, with nearly clean and 
pale-red edges; the bowels are irregular, being sometimes costive, 
and at others affected with diarrhoea. In cases of this kind, the 
pulse is seldom perceptibly affected in the forepart of the day; 
but in the afternoon, and particularly towards evening, it gen- 
erally becomes somewhat accelerated, contracted, quick and 
sharp. The surface is seldom above the natural temperature, 

* Dr. H. Wolff, of Bonn, is I believe, the first who has described this disease, as it 
occurs in infants. He describes it as " a peculiar form of ascites in children," in a paper 
published in Hufeland's and Osann's " Journal des practischen Heilkunde" for May, 
1829. I have not seen Dr. Wolff's memoir on this subject; and avail myself of an in- 
teresting review of it, published in the 7th vol. of the North American Medical and Sur- 
gical Journal. 



392 PERITONITIS. ASCITES. 

except during the slight evening exacerbations, when it becomes 
preternaturally warm and dry. 

The disease does not, however, always commence and proceed 
in this obscure manner. In some cases, " the pain in the abdo- 
men is constant, severe, and much increased by external pres- 
sure, and is attended -with vomiting, a hot skin, a quick, firm 
and contracted pulse," and great muscular debility. 

After these symptoms have continued for an indefinite period, 
varying from five to fifteen or twenty days, effusion begins to 
take place into the cavity of the peritoneum, and the abdomen 
gradually becomes enlarged. The nature of the abdominal dis- 
tention is rendered manifest by the fluctuation produced by per- 
cussion. If the progress of the disease be not interrupted, " the 
abdomen gradually increases in size; the inferior extremities 
become emaciated; the skin at the upper and inner part of the 
thighs, hangs infolds; the fluctuation of the abdomen becomes 
less perceptible as the disease advances, while the tumefaction 
continues unabated. Every part of the body, with the exception 
of the face, becomes emaciated; the little patient loses rapidly 
its strength; the lower extremities are no longer able to bear the 
weight of the body: in the midst of these symptoms, the appetite 
may, however, continue, or even be increased. The bowels 
are in general variable, being at one time affected with diarrhoea, 
at another constipated, or at least seldom opened. A febrile ex- 
citement now occurs, and the child, in a state of extreme maras- 
mus, sinks gradually into its grave." (Wolff.) The writer just 
quoted, mentions a peculiar appearance of the countenance occur- 
ring in the second or hydropic stage, which he regards as one of 
the most certain diagnostic signs of the disease. " The appear- 
ance referred to, consists of a tumefaction of the skin at the root 
of the nose, immediately between the eyes." " The parents of 
my patients," he says, " frequently noticed a change in the expres- 
sion of the countenance, without being able to say in what it 
consisted; but as soon as I directed their attention to the tume- 
faction of the skin at the spot mentioned, they agreed with me, 
that the change in the appearance of the child's countenance 
arose from it, and were surprised, they had not discovered it 
themselves." 



PERITONITIS. ASCITES. 393 

Causes. — This disease appears to be frequently the consequence 
of gastro-intestinal irritation: or rather of mucous inflammation 
of the alimentary canal — the inflammation passing from the mu- 
cous membrane, to the peritoneal covering of the bowels. Crude, 
irritating and indigestible articles of nourishment, are probably 
the most common exciting causes of this affection in children. 
I have witnessed two cases within the present year, both of 
which were preceded by prominent symptoms of intestinal irri- 
tation, for many weeks before the peritoneal affection became 
obvious. In adults, I have met with several very striking instan- 
ces of subacute peritonitis, and consequent serous effusion into 
the abdomen, brought on by acute mucous inflammation of the 
bowels, in consequence of irritating ingesta. There are, doubt- 
less, various other causes which may give rise to this affection 
in children. It may be the result of acute or chronic inflamma- 
tion of the solid abdominal viscera — particularly of the spleen and 
liver. Blows and other injuries inflicted on the abdomen; 
repelled cutaneous eruptions; cold, and perhaps protracted con- 
stipation, may give rise to the disease. 

When properly treated during the first stage, this disease may, 
in general, be readily subdued. " Even in the first period of 
the stage of effusion, it is by no means incapable of being arrested; 
but when neglected., mismanaged, or submitted to medical treat- 
ment only in the advanced period of the second stage, as is but 
too commonly the case, death is the ordinary result." The great 
difficulty, indeed, arises from the gradual and obscure manner 
in which the disease frequently advances through its inflamma- 
tory stage, so that very few cases are recognized or properly un- 
derstood, until effusion has taken place. During the first or inflam- 
matory stage, the symptoms are usually ascribed by the parents, 
to worms. Anthelmintics are accordingly resorted to, which 
seldom fail to aggravate the disease, and to hasten its progress 
to an incurable state. Dr. Wolff asserts, that " most of the severe 
cases which had fallen under his notice, were those in which 
anthelmintics had been administered, either by the parents, or 
occasionally by a physician, on the first appearance of the symp- 
toms, from a supposition that they owed their origin to the exis- 
tence of worms in the intestines." This practice, he says, is 

3 E 



394 PERITONITIS. ASCITES. 

extremely pernicious. "For although, in a few instances, worms 
may be discharged, yet so far from the patient's disease being 
removed, every symptom becomes aggravated; the pain of the 
abdomen increases in intensity, and is rendered more constant; 
vomiting is excited, the appetite is entirely destroyed, the thirst 
augments, the febrile symptoms are rendered more marked; and 
the patient is apt to suffer severe attacks of colic, soon after 
eating." 

Treatment. — During the inflammatory stage, local depletion, 
and counter-irritating applications to the abdomen constitute our 
principal remedies. After blood has been abstracted by leech- 
ing, to an extent corresponding with the age of the patient, and 
violence of the local symptoms, a large blister should be applied 
to the abdomen, and kept discharging by dressing it with mercu- 
rial ointment. I have never in children derived any decided 
benefit from pustulation with tartar emetic ointment. The warm 
bath, and fomentations to the abdomen, may also be used with 
advantage. Internally, small doses of calomel and ipecacuanna, 
should be regularly administered. A fourth of a grain of each 
may be given three or four times daily; but if no mercurial oint- 
ment is used externally, the quantity of calomel should be increased 
to a half a grain. Should the calomel not keep the bowels suffi- 
ciently loose, a small dose of castor oil must be occasionally ad- 
ministered. To allay general irritation, a few grains of Dover's 
powder may be given in the evening with much advantage. 
Throughout the whole course of the disease, the patient should 
be restricted to the blandest and simplest articles of nourish- 
ment. Without strict attention to this important injunction, 
there can be but little hope of a cure in this affection. Arrow- 
root, tapioca, sago, rice, boiled milk and crackers, barley water, 
weak chicken tea, etc., constitute appropriate articles of diet. 
In the second stage, that is, after effusion has taken place into 
the abdomen, leeching may still be useful if the abdomen be 
tender to pressure. At this period of the disease, much benefit 
may sometimes be derived from frictions on the abdomen, with 
mercurial ointment. Laennec and Velpeau speak in the most 
favorable terms of this practice; and my own experience has 



PERITONITIS. ASCITES. 395 

furnished me with unequivocal evidence of its usefulness. Dr. 
Wolff strongly recommends calomel, with very minute portions 
of digitalis; and at a still more advanced period, "digitalis with 
cream of tartar in the form of powders." He asserts, that under 
the use of these remedies, most of the patients he treated became 
convalescent, at the end of two, three, or at most four weeks. 
Whether mercury be used externally, as recommended by Laen- 
nec, or internally, digitalis, is doubtless a most important auxil- 
iary, and should never be omitted after effusion has taken place. 
Irritating diuretics, and drastic purgatives, are extremely impro- 
per. They never fail to aggravate the disease. 



396 VACCINA. VACCINE DISEASE. 



CHAPTER XXXIV. 



VACCINA. VACCINE DISEASE. 



Much uncertainty still hangs over the origin of the vaccine 
disease. The opinion that it is derived from the complaint in 
horses, denominated grease, is sustained by very imposing, though 
not conclusive, evidence. We have excellent authority for be- 
lieving, that inoculation with the virus of grease, occasions an 
eruption in the human subject and cow, precisely similar to that 
arising from vaccina. Loy, Sacco,* Decarro of Vienna, and 
Frise, director of vaccine inoculation in Silesia, have all perform- 
ed this experiment, according to their several statements, with 
perfect success; and so well assured were the two latter gentle- 
men, of the identity of the two infections, that it is said they 
used indiscriminately the matter of grease and of vaccina for 
inoculation. Cazenane met with two cases in the hospital of 
St. Louis, of true vaccine disease on the hands of grooms, having 
the care of horses affected with grease. By the application of 
the recent blackish matter of this complaint, to the raw surface 
of a sore on the teat of a cow, Ring succeeded without difficulty 
in producing genuine vaccina. The same gentleman publishes a 
letter from Mr. Rankin, wherein is related a case of pustular dis- 
ease, closely resembling the vaccine affection, produced on the hands 
and face of a farmer by the virus of the equine disorder. Be- 
sides, it would seem probable, that persons infected with a pus- 
tular disease from this source, enjoy an immunity from the con- 
tagion of small pox. Dr. Jenner has recorded a case of this 

* Neue Entdeckungen uber die Kuhpocken, die Maukc u. Schaafpocken. Translated 
from the Italian by W. Sprengel. 1813. 



VACCINA. VACCINE DISEASE. 397 

kind. There can be no doubt, however, that further and more 
careful observations are requisite to the formation of a correct 
judgment on this point. Dr. Jenner supposes, that the infection 
of grease is transmitted through the intervention of the male 
domestics, who, after dressing the heel of the horse, proceed 
without cleansing themselves to aid in milking the cow. But, in 
several countries where vaccina is prevalent, it is well known 
that the grooms have nothing to do with the offices of the dairy; 
and in America, where horses and cows are attended to by 
different persons, the latter are sometimes affected with the dis- 
ease, though running in pastures from which the horse is exclu- 
ded. These facts, though they do not disprove the similarity of 
the two viruses, throw many difficulties in the way of accounting 
for one as the consequence of the other. 

It is now well known that sheep are subject to an eruptive 
disease about the mouth and head, the matter of which being 
inoculated, will produce effects very similar to those of grease. 
It is also affirmed, that persons, to whom this infection has been 
communicated, are rendered insusceptible to the contagion of 
variola. We find this fact stated in a letter, addressed by Mr. 
W. Bruce, consul at Bushire, to Erskine of Bombay. After 
very extensive and cautious enquiry, he felt justified in yielding 
full credence to the report of several tribes of the natives, 
that those of them who attended to the flocks, were not unfre- 
qently affected with an eruptive malady, caught from the sheep 
amongst whom it widely prevailed, and were thereby completely 
secured against the attack of small-pox. Sacco and • Richter 
likewise bear testimony, that inoculation with this infection 
confers on the human subject an exemption from the contagious 
influence of variola. 

The curious circumstances we have mentioned in relation to 
the marked affinity subsisting between the various eruptive dis- 
orders furnish no slight grounds for the opinion, that they are all 
essentially identical in their nature, and derived from the same 
ultimate source. The hypothesis with regard to variola is, that 
it was originally nothing more than the cow-pock, or the grease 
of horses in Arabia, transferred casually or otherwise to the hu- 
man system, and that by such transference and by its continuous 



398 VACCINA. VACCINE DISEASE. 

propagation through the human species, it gradually deteriorated, 
until it had acquired all the virulence and activity of what is 
now termed small-pox.* This hypothesis is by no means extrava- 
gant. It would seem from experiment, that the milder sort of 
small pox under proper management, may be made to assume 
by successive inoculations so meliorated a form as hardly to be 
distinguished from vaccina. Dr. Adams inoculated a certain 
number of children, with lymph taken from the pustules of a mild 
variety of variola, denominated by him the pearl sort. With the 
matter of the mildest of the resulting cases, he inoculated a sec- 
ond number, and so on, till he produced a small pox so melio- 
rated as to resemble the vaccine disease. If small pox can thus 
be made to take on the gentle nature of the vaccine disease, the 
inference is, that vaccina under certain circumstances may have 
acquired all the virulence of the variolous contagion. Another 
argument in favor of the identity of the two affections, grows out 
of the commonly received fact, that two diseases, arising from es- 
sentially distinct contagions, cannot exist simultaneously in the 
same individual. If a subject for example, be inoculated at the 
same time with the virus of small pox and that of measles, the 
influence of the one will be entirely suspended, until the other 
has commenced and finished its course, when it too will develope 
itself and run its usual career uninterruptedly. Now if the 
matter of vaccina, and that of variola be inserted at once in sep- 
arate parts of the same body, the eruptive distemper resulting, 
will pursue a simultaneous course, exhibiting precisely the same 
character, as if their respective viruses had been inoculated at 
different periods. This is probable evidence of their original 
identity, how dissimilar soever they may have been rendered by 
accidental circumstances. But positive evidence is not wanting 
to sustain this point. Cases are recorded where variolous matter 
inserted in the udders of cows, produced in them a pustular affec- 
tion, not to be distinguished from cow-pox. This observation is 
made by Richter on the authority of Garsner.t We may also 
remark here, on the authority of Da Lisa, that sheep, inoculated 
with the virus of variola, are protected entirely from what is 

* Dictionnaire des Sciences Medicales. 
t Speciell Therapie. 



VACCINA. VACCINE DISEASE. 399 

called sheep-pox. Inoculation in them is said to produce but one 
pustule at the point of insertion.* If we may rely on the correct- 
ness and veracity of Dr. Ozaman, of Lyons, and more recently, 
of Dr. Sunderland, of Barman, the original identity of vaccina 
and variola, is established beyond doubt. The former in a paper 
read in the French Academy of Medicine, in July, 1830, asserts, 
that the inoculation of variolus matter, mixed with fresh cow's 
milk, will develope an eruption similar in all respects to that 
occasioned by the vaccine virus, and will fully answer for the in- 
ductions of the usual vaccine disease.! Dr. Sunderland's experi- 
ments;]; would seem still more conclusive. The following experi- 
ment performed by him is so interesting, we will give it in detail. 
A woollen bed cover is permitted to lay on the bed of a patient 
who has died of small-pox in the suppurative stage, or who, placed 
in a narrow and badly ventilated apartment, is suffering from the 
disease in a considerable degree, until it is well saturated with 
the contagion. It is then rolled up, wrapped in linen, and spread 
for twenty-four hours on the back of a cow, in such a way that 
the animal cannot throw it off. In the same manner, it is ex- 
tended on the back of each of three other cows, for the same 
length of time; after which it is so suspended in their stall, that 
they may constantly inhale the contagious effluvia as they arise. 
In the course of a few days the animals become sick and fever- 
ish-, and on the fourth or fifth day, a pustular eruption breaks 
forth upon the udders and other parts, covered with hard skin 
and displaying the usual appearance of the vaccine disease, soon 
becomes filled with lymph. Inoculation with this lymph, which 
precisely resembles the matter of genuine cow-pock, will produce 
perfect vaccina. 

Symptoms and Progress of Vaccina. — There are two varie- 
ties of vaccina, the casual and inoculated. The casual cow-pock 
is apt to affect the joints and tips of the fingers of domestics, hav- 
ing the care of cattle laboring under the vaccine disease. It is 
always more severe than the inoculated variety, on account of the 

* JVIediz. Chirur. Zeit. 1809. No. xliii. Salsbury. 

+ Rev. Encyclop. Aout. 1830. 

^ Journal der Prakti^chcn Heilskundc, Jannar. 1831, 



400 VACCINA. VACCINE DISEASE. 

number of vesicles produced, and the membranous-, rigid struc- 
ture of the parts involved in the eruption. Inoculated vaccine 
is, in general, indicated by one pock alone, and its whole course 
may be divided into two periods. 

1st. The first period commences towards the close of the second 
day after the insertion of the virus, at which time may be discern- 
ed a minute point of inflammation at the spot where the puncture 
was made. This point is more distinct on the third day, and on 
the fourth, it has the form of a very small pimple, surrounded by 
a faint and narrow inflamed areola. There is a gradual enlarge- 
ment of the pimple, and on the fifth day, it begins, to display a 
perfectly regular and circumscribed outline with a flattened sur- 
face, and a small depression at the centre, somewhat darker than 
the rest of the surface, — an appearance it retains throughout its 
whole subsequent course. The pimple about this time becomes 
a vesicle, containing a limpid fluid, and presents a dull whitish 
aspect. From the fifth to the ninth day, the circumference of 
the pock continues to enlarge, without its elevation being percep- 
tibly increased, so that its flattened appearance becomes still 
more remarkable. 

2. The second period begins at the full maturity of the pustule, 
which takes place on the ninth, when constitutional derangement, 
if any occurs, is apt to supervene. In some instances, the axil- 
lary glands at this period become irritated and swollen, and the 
patient complains of drowsy languor and faint creeping chills, 
alternating with flushes of heat. Constitutional symptoms are 
not unfrequently altogether absent. By the tenth or eleventh 
day, the belt of inflammation around the pustule, that began on 
the eighth day to widen, has become a broad, beautiful and viv- 
idly red areola encircling the pock. The areola is now perfect, 
and attended with some degree of tumefaction and hardness. 
The central indentation of the pustule begins, on the eleventh 
day, to assume a darker hue, and this darkness gradually spreads 
towards the circumference: so that by the fourteenth day, the 
surface of the pock is transformed into a brown scab, which grows 
darker and darker, acquiring a deep brown or mahogany color. 
In a few days more, the circumference of the scab becomes loos- 
ened, but the centre still retains its attachment, till between the 



VACCINA. VACCINE DISEASE. 401 

third and fourth week from the time of vaccination: the whole 
then falls off, leaving a slight, regularly defined depression in the 
skin, and a scar which is indelible. 

Deviations. — Such is the ordinary course of the disease, for it 
is occasionally subject to deviation. The period, for example, 
intervening between the insertion of the virus and appearance of 
the pustule, is sometimes prolonged to the tenth, fifteenth or 
even twentieth day. In some cases, the whole course of the disease 
is completed in eight or nine days, well-formed lymph being pro- 
duced by the fourth day. When the umbilicated indentation in 
the centre of the pustule is wanting, there may be two pus- 
tules, partially blending with each other. It is seldom that inoc- 
ulation produces more than one pock, but occasionally one or 
more smaller pustules manifest themselves in the vicinity of the 
primary one. Instances indeed have occurred, where they ap- 
peared in considerable numbers on different parts of the body. 
In the report of the central vaccine committee of France in 1818, 
19, it is stated that a spontaneous eruption of many pustules had 
occurred in several cases after vaccination; and moreover, that the 
matter of this eruption had the power of inducing as perfect a 
disease as that excited by the virus of the primary pock. 

Considerable inflammation sometimes supervenes on the day 
succeeding the vaccination, and an elevation of the cuticle 
takes place at the point where the puncture was made. In this 
case, the failure of the operation may be considered certain. The 
inflammation, after continuing a day or two, speedily subsides, 
without leaving any local affection. 

Instead of a vesicle, a true pustule is occasionally formed, the 
inflammatory action arising on the day after the vaccination, or, 
at the furthest, on the succeeding one. A well-defined areola en- 
circles the pustule, in which instead of a depression, there is a 
conspicuous elevation of the centre above the ridges. Its increase 
is rapid, and about the fifth day, it is converted into a yellowish 
brown scab, which soon disappears without leaving any scar. In 
this case, also, the operation is abortive and should be repeated. 

Spurious Pock. — According to Willan, there are three varieties 
of spurious pock. In the first, though the vesicle is perfect, there 

3F 



«"3m 



402 VACCINA. VACCINE DISEASE. 

is no areola around it on the ninth or tenth day. In the second, 
the vesicle is much smaller than the genuine vesicle, and is pearl- 
colored, flattened, without a rounded or prominent margin, with 
a hard, inflamed and slightly elevated base, and an areola of a 
dark-red color. The vesicle in the third variety, is small and 
pointed, with a very extensive, pale-red areola. The areola in the 
two latter varieties, are observable on the seventh or eighth day, 
and disappear about the tenth. A very small scab is then formed, 
which is not so regular in its shape as that of the true vesicle. 
The spurious disease may arise from the following causes; 1st. 
The existence of some cutaneous distemper, capable of counter- 
acting or perverting the action of the genuine vaccine virus. 2d. 
Certain idiosyncrasies, or a depraved condition of the system, 
vitiating or impeding in some way the regular operation of the 
virus. 3d. Vaccination with spurious matter, or with genuine 
matter whose virtues have been impaired by long keeping; or 
with matter taken from a true vesicle at too late a period. Beside 
these, friction with the clothes, or by other means, so as to cause 
a rupture of the vesicle, and the frequent abstraction of its lymph 
by punctures, may be considered as depriving the disease of its 
genuine character. 

The spurious and true cow-pox sometimes pursue their course 
simultaneously in the same individual, in which case it does not 
seem that the protective power of the genuine virus is in any de- 
gree diminished. 

Diagnosis. — In attempting to distinguish true vaccine from 
false, we should carefully observe the following particulars: 

1st. In the genuine disease, inflammation, saving that which 
occasionally arises from the irritation of the puncture, is scarcely 
observable until the third day, and sometimes considerably later. 
On the other hand, the spurious affection is marked by an ele- 
vation of the cuticle and no slight degree of inflammatory action, 
so early as the second day. 

2d. The small inflamed point, in true vaccina, appearing in 
two or more days after the insertion of the virus, has a gradual 
increase until the seventh day after its first manifestation, when 
it is in a state of perfection. The spurious pustule becomes ma- 



/ 



VACCINA. VACCINE DISEASE. 403 

tured, and finishes its course in, a much shorter time; the scab- 
bing commences on the third or fifth day after the development 
of inflammation. 

3d. A beautiful, circular, and well-defined areola almost always 
surrounds the pustule of genuine vaccina, and is seldom perfect 
until the seventh or eighth day. In the false disease, the pus- 
tule is begirt with an irregular, superficial inflammation, super- 
vening on the first or second day after the appearance of the pus- 
tule; and the pustule itself is more like a common festering sore 
occasioned by a thorn, than a pustule excited by the vaccine 
virus. 

4th. The genuine pustule is perfectly and regularly defined, 
with a flattened surface, and a slight central indentation, and con- 
tains a colorless, limpid fluid. The spurious pock is more eleva- 
ted, not depressed in the centre, is irregularly circumscribed, and 
contains an opaque purulent matter. 

Remediate Treatment. — General remediate treatment is rarely 
required in the inoculated form of vaccina. Febrile excitement 
occasionally exists, and even a slight exanthema may appear, in 
which case we should direct a low diet, diluent drinks, and a gen- 
tle aperient, together with spiritus mindereri or sweet spirits of 
nitre. The vesicle should be especially shielded from friction, 
whereby it is apt to be greatly irritated, particularly about the 
time when the areola is making its appearance. From friction 
or other cause, the inflammation and swelling around the pustule 
sometimes become so severe as to demand immediate relief. Cold 
water, a weak solution of sugar of lead, or poultices made of lead- 
water, should be applied to the part, to allay pain and inflamma- 
tion, at the same time that laxatives, with some of the milder 
refrigerant diaphoretics are given internally to subdue febrile 
irritation. 

The relation of Vaccina with other diseases. — I have 
thought it proper to defer until now, the consideration of the 
relation of the vaccine disease with other affections, that I might 
present in a connected form all I have to say on this part of our 
subject. It was early noticed, that the infection of vaccina had a 



404 VACCINA. VACCINE DISEASE. 

tendency to correct a general depravation of the system and to 
remove various chronic complaints, especially those of the lym- 
phatic and cutaneous systems. There are well authenticated 
cases, in which crustea lactea, scrophulous ophthalmia and tumors, 
and certain varieties of scaly tetter have been entirely cured by 
the constitutional influence of the vaccine virus. Herpetic erup- 
tions, after vaccination, not unfrequently assume an appearance 
resembling that of vaccine pustule, and fade away with the de- 
siccation and falling off of the scab. Violent whooping cough has 
been arrested at the moment of the appearance of the eruption, 
and permanently cured. Of the power of vaccina to mode- 
rate and abridge the course of pertussis, I have myself witnessed 
many examples. In this respect, it differs greatly from both 
casual and inoculated small pox, which have been known to ex- 
cite the active developement of disorders, to which there existed 
previously a latent disposition, In accounting for these peculiar 
effects of the vaccine disease, we can hardly suppose that its in^ 
fluence over other disorders is specific in its nature, otherwise it 
would be more constantly and uniformly exerted. It may be consid- 
ered rather the result of an irritation, universally diffused through- 
out the system, penetrating the minutest portion of living fibre; for 
it is well known that the creation of a comparatively slight gen- 
eral irritation is sufficient, at times, to relieve a graver disorder 
already existing. We may observe, that the meliorating influ- 
ence of vaccina over other complaints, is generally more mani- 
fest, when a considerable degree of irritation is produced. 
Hence, when such an influence is desirable, it may be proper 
to insert the virus by several punctures. 

The diminution in the prevalence of small pox, occasioned 
by the general introduction of vaccination, is, if we may be- 
lieve Dr. Watt, very curiously associated with the increase of 
measles. His observations, which are restricted to Glasgow, go 
to prove, that the increase of measles in that city, since the 
adoption of vaccination, has borne a nearly equal proportion to 
the decrease of small pox. If such be the fact, it should perhaps 
be ascribed to peculiar local causes, especially as further obser- 
vations have afforded no countenance to his opinions. 



VACCINA. VACCINE DISEASE. 405 

As a prophylactick against that terrible scourge the small pox, 
the virtues of the vaccine disease are now happily and extensively 
known. 

Origin of Vaccination. — Dr. Jenner has the inestimable honor 
of introducing this operation to the notice of the world; but 
long before his time, it had been known by agriculturists in some 
parts of England, that an infection in the hands and about the 
joints of the fingers received from a cow laboring under what is 
now called vaccina, would confer an immunity against the small 
pox. Benjamin Jesty, a farmer of Downbay, in the isle of Pur- 
beek, so early as the year 1774, inoculated himself, wife, and two 
sons, with virus taken from the pustules on a cow's udders, suf- 
fering with the vaccine disease. He did this, to protect himself 
and family from the attack of small pox, at that time prevalent 
in the vicinity. The operation was perfectly successful.* But 
the prophylactick power of the vaccine disease had not only been 
previously known in the dairy counties of England, but also in 
different parts of Europe, and, if we may rely upon the testimony 
of Humboldt, even in several districts of South America. It has 
been attempted, unsuccessfully as we think, to prove that the 
first suggestion of the expediency of inoculation with vaccine 
virus, was made by a native of France to an English physician, 
and by him communicated to Dr. Jenner. But from whatever 
source this gentleman may have derived the notion of vaccina- 
tion, to him alone must be awarded the honor of its first intro- 
duction to general notice. Successful experiments were per- 
formed by him with vaccine matter, so early as the year 1796, 
but the result of his enquiries was not, until two years after, an- 
nounced to the public. From that period on, the knowledge of 
the virtues of vaccination spread rapidly throughout Europe and 
this country, and there is now no civilized people on earth, 
amongst whom its blessings have not been realized and gratefully 
acknowledged. 

Prophylactick power. — For a while the prophylactick pow- 
er of vaccination was generally thought to be complete and 

* Edinburgh Journal, vol. 1st, p. 513. 



406 VACCINA. VACCINE DISEASE. 

universal, and whoever presumed to hint doubts of its efficacy in 
any case, was sure to meet with the indignation or contempt of 
the profession. Since then the general sentiment has undergone 
a considerable change. From some cause or other, as yet unre- 
vealed, so many well-attested cases of failure in the preventive 
power of vaccination have taken place, and so remarkable of late 
years has been the progressive increase of such cases, that the 
vaccine disease is no longer considered by practitioners a sum" 
cient safeguard in every case from the variolous contagion. "This 
circumstance," says Dr. Gregory, "cannot be met by a reference 
to the fact, that small-pox once gone through does not always pro- 
tect the subject from a second attack." Cases of variola after 
vaccination are far more frequent than second attacks of that dis- 
ease. Dr. Gregory has given a table of the total number of ad- 
missions into the small-pox hospital, in ten different years. From 
this statement it appears, that in the year 1810, the proportion of 
cases of small-pox after vaccination to the whole number of ad- 
missions, was as 1 to 30, while in 1815, it was as 1 to 17; in 1821, 
as 1 to 4; and during the year 1823, as 1 to 3*. We may remark, 
however, that as this is the register of a single hospital, certain 
local circumstances may have occasioned the augmenting ratio of 
cases: no general conclusion can therefore be legitimately drawn 
from the facts set forth. The statement, moreover, may be inex- 
act, seeing there could be no infallible method of determining 
whether the vaccination had been genuine and produced its con- 
stitutional effects. 

Notwithstanding these facts, vaccination must still be regarded 
as an invaluable means for lessening the amount of mortality, and 
as deserving all confidence as a protecting power against small- 
pox. For although it may not, in many cases, render the system 
wholly insusceptible to the variolous infection, yet the number of 
instances in which it affords perfect immunity from small-pox, is 
beyond all comparison greater than that in which it fails to afford 
complete protection; and even where it does not entirely subdue 
the susceptibility to the small-pox, it almost invariably lessens it to 
such a degree, as to render this latter disease so mild and simple, 
as in most instances scarcely to require any remediate attention. 

By many it is believed, that the constitutional influence of the 



VACCINA. VACCINE DISEASE. 407 

vaccine virus gradually wears out, until the system regains its 
original susceptibility to the contagion of small-pox. In opposi- 
tion to this hypothesis it is remarked, that variolous cases occur 
with nearly equal frequency at all periods after vaccination, — as 
many indeed being met with at one year, as at five, ten or fifteen 
years subsequently to that operation. The results of experience 
however, are favorable to the hypothesis. Some have limited the 
vaccine impresskm to ten years. Dr. Brown has inferred from 
his observations, that immediately after vaccination, the antiva- 
riolous influence of the virus is nearly perfect; that in about three 
years afterward, the created insusceptibility is so much diminish- 
ed, as readily to allow the operation of the variolous contagion; 
although the disease then occurring will appear in a mitigated 
form; that at the period of five or six years, hardly any security 
from small-pox is enjoyed, and so diminished is the influence of 
the vaccine virus, that if variola do occur, it will very nearly ap- 
proach in severity to the natural disease; lastly, that the consti- 
tutional influence of vaccina cannot be depended upon any longer 
than six years from the period of vaccination. Dr. Leo 
WoolrT, in an interesting memoir on this subject, has adduced 
facts and reasonings to show, that the vaccine influence is effaced 
by the constitutional changes that take place at the period of pu- 
berty. That the prophylactic power of vaccination progressively 
diminishes, until it is perhaps entirely, worn out, I am myself 
much inclined to believe, from facts that have come under my 
own observation. But the attempt to determine its gradual sub- 
sidence by any accurate, fixed periods, must necessarily be an 
almost impracticable task; since it may well be supposed, that 
idiosyncrasies, modes of living, accidental as well as innate pre- 
dispositions, and perhaps habitual extraneous agencies, may occa- 
sion many variations in this respect. The general fact or possi- 
bility of the gradual effacement of the constitutional influence of 
vaccina, should admonish us of the propriety of re-vaccinating, in 
order to renew the prophylactic impression. This practice is certain- 
ly rational, and cannot be detrimental, as a precautionary measure. 

The manner of Vaccinating. — Vaccination has been perform- 
ed in three ways — by blistering, incision, and puncture. The 



408 VACCINA. VACCINE DISEASE. 

first, being apt to create an irritation detrimental to the vaccina- 
tion, and the second, endangering the washing away of the virus 
by the great flow of blood, are now generally superseded by the 
method of puncture. The spot usually selected for the operation 
is at the lower insertion of the deltoid muscle. The posterior 
part of the arm of the person to be vaccinated, is to be firmly 
grasped with one hand, while with the other, the lancet, at whose 
point is a tangible drop of the virus, is to be inserted a few lines, 
from above, downwards. It should be continued a few moments 
in the puncture, and its point pressed against the lower surface 
of the wound. It is expedient to make several punctures, merely 
that the chances of a successful operation may be increased. 

The character of genuine Virus. — The vaccine lymph, up 
to the time when it begins to desiccate, is a limpid, viscous liquid, 
colorless, inodorous, and of a salt, acrid taste. Exposed on a 
smooth, fiat surface, it dries rapidly, but without losing its tran- 
sparency. Chemical observation has taught us, that it is decom- 
posed and rendered inert by the action of light, and heat; and 
that even at the ordinary temperature, the continued influence of 
the atmosphere greatly impairs its virtues. To obtain the virus, 
the edges of the pustule must be punctured in several points. 
The lymph will then ooze out, and may be collected and preser- 
ved between glass plates; Jenner recommends that it should be 
taken just before the appearance of the areola. He thinks its 
virtues diminished after the manifestation of the efflorescence, 
and always, if possible, avoided collecting it beyond the eighth 
day. Of late years, and especially in this country, vaccination is 
most commonly performed from the scab. The virus may be 
preserved longer uninjured, in the form of scab, than in any 
other mode. Matter of six or even ten months old, if kept in this 
way, will readily communicate the infection. No scab, except 
from a perfect pustule, should be taken. It ought to be smooth, 
of a dark-brown, or mahogany color, and rather brittle than 
tenacious in its texture. When used, the margin, which is of a 
lighter hue than the rest, should be removed with a knife, and a 
portion of the remaining dark, hard, internal part reduced to 
powder on a glass, and moistened or dissolved in a little cold water. 



VACCINA. VACCINE DISEASE. 409 

In whatever way the virus be procured, we ought carefully to 
examine whether the person, from whom it is taken, be in a 
healthy state; whether he may not be the subject of some cutane- 
ous affection, or a vicious constitutional taint. Carelessness on 
this point may result in incalculable injury. I have several times 
known obstinate and alarming cutaneous distempers communi* 
cated to children by vaccination with virus from an unhealthy 
person. Unprofessional people have a notion, that various trou- 
blesome eruptions are occasioned by the vaccine disease; and it 
is somewhat sanctioned by enlightened observation. Accidents 
of this kind, however, may for the most part be charged upon that 
carelessness, of which we have just spoken. 

The condition of the person to he vaccinated. — Age generally 
would seem to have little or no influence on the success of this 
operation. Certain idiosyncrasies are occasionally met with in 
persons of every age, counteracting completely the action of the 
virus; and sometimes cases occur, in which several successive 
operations are requisite, before success is obtained. Vaccination 
is commonly performed in childhood; but, as a general rule, it 
should not be attempted in children under six weeks old. The 
constitutional disturbance, occasioned by the agency of the virus, 
is more considerable in mature years, than early life. The ex- 
istence of disease does not generally contra-indicate the propriety 
of the operation, if we except herpetic eruptions and some other 
cutaneous disorders. Nor does dentition nor pregnancy consti- 
tute any valid objection to its performance, provided there be no 
severe derangement of the nervous system. 

As to the season for vaccination, it appears to be equally suc- 
cessful throughout the year. It would seem, however, that the 
course of vaccina is retarded by cold and hastened by hot 
weather. 

The fact, that important varieties and modifications of the vac- 
cine disease are occasioned by the existence of certain cutaneous 
affections, is well established, and merits particular attention. 
Dr. James, in a paper published in the sixty-sixth number of the 
London Medical and Surgical Journal, states that a single serous 
blotch on the skin, during the progress of the vaccine vesicle, 

3G 



410 VACCINA. VACCINE DISEASE. 

may cause such irregularity, and deviation from the natural course 
and character of the disease, that it cannot he depended on as a 
prophylactic against the variolous infection. In a letter addressed 
hy him to the medical profession generally, in April, 1821, he 
observes — " I have observed abrasion of the cuticle produce the 
same effect, — such, for example, as we find in the nurseries of the 
opulent, as well as in the cottages of the poor, behind the ears and 
on many other parts, where the cuticle is tender. We find irre- 
gularity in the vaccine vesicle, if the skin is beset with herpetic 
blotches, or even simple serous oozings from an abraded cuticle. 
A speck behind the ear, that might be covered with a split pea, 
is capable of disordering the progress of the vaccine vesicle." 

Test of vaccination. — The increasing number of failures in the 
protective power of vaccination, has by many been attributed, in 
great part, to an insufficient inoculation. It is, therefore highly 
important, to ascertain, in some way, whether the constitutional 
impression of the virus has been procured. Bryce's method of 
determining was, to re-vaccinate with matter from the pustule of 
the first vaccination, at the end of the fifth or beginning of the 
sixth day after the operation, between thirty six and forty eight 
hours before the appearance of the areola. If the disease be per- 
fect, a pustule will arise at the point of the second insertion, but 
it will become accelerated in its course, so that about the second 
or third day from its coming forth, it will be surrounded with an 
areola, increasing and fading away, pari passu, with that of the 
first pustule. If, on the contrary, the first disease be not sufficient, 
the irruption from the second insertion will pursue its regular 
course as in other cases. This is now to be regarded as the pri- 
mary disease, and the same method of re-vaccination is to be 
practised, with matter from its pustule, — and so on, until a perfect 
affection shall be induced. Others have proposed to re-vaccinate 
about twelve days after the operation. If this has been sufficient, 
the second vaccination will either not succeed at all, or give rise 
only to a spurious or an irregular pock. But the most certain 
test is inoculation with small-pox matter, — a test, from which we 
derive at once our reliance on the general protective power of 
the disease, and on its efficacy in the particular case. 



VARIOLOID DISEASE. 411 

A distinct, circular, radiated, punctulated, and not very large 
cicatrix is a pretty certain indication, that the vaccine affection 
was perfect. When the scar " is large, and bears the marks of 
having been formed by high local inflammation, and wants the 
distinct